397003771-1-10-2022-27-AS-KHOS-CBPNBC-20220216091854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 01/10/2022
Date Signed: 01/10/2022 12:31:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211214154259

FACILITY NAME:	BROOKDALE LODI		FACILITY NUMBER:	397003771
ADMINISTRATOR:	MARY MARGARET CHAPPELL		FACILITY TYPE:	740
ADDRESS:	2220 W. KETTLEMAN LANE		TELEPHONE:	(209) 367-8870
CITY:	LODI	STATE: CA	ZIP CODE:	95242
CAPACITY:	82	CENSUS: 42	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mary Margaret Chappell, Executive Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident was injured while in care.
Staff did not respond to resident's calls for assistance.
Facility staff did not ensure that diabetic resident was fed timely.

INVESTIGATION FINDINGS:

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On 01/10/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegations. LPA White discussed the purpose of the visit and the elements of the allegations with Executive Director, Mary Margaret Chappell.

During the course of investigation, LPA White interviewed 4 staff members and 4 residents. LPA collected the following documents for Resident #1 (R1): Physician Report (LIC602), Identification and Emergency Information, Needs and Service Plan, Progress Notes, Room Service Slips and Pendant tracker within the last 30 days.

Report Continues at 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211214154259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE LODI	FACILITY NUMBER: 397003771
	VISIT DATE: 01/10/2022

NARRATIVE

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Resident was injured while in care.
On 12/16/2021, LPA spoke with Resident #1 (R1) regarding injuries while in care. Based on interview, R1 attempted to lower bed and the table tilted over. R1 stated, she almost fell out of the bed. R1 stated she twisted her arm and back. Based on interview, Staff #3 (S3) and Staff #4 (S4) stated R1's table had fallen and S3 picked it back up. S3 stated she did not observe any injuries. Based on Staff #1 (S1), R1 moved out of the facility on 12/20/2021. LPA is unable to prove or disapprove if allegation occurred.

Staff did not respond to resident's calls for assistance.

On 01/10/2022, 3 of 4 residents stated they use there pendants. 3 of 4 residents stated when their pendants are pressed, staff respond in a timely manner. 4 of 4 staff stated residents pendants are always answered. LPA collected and reviewed pendant history for R1. Based on documentation, R1 had a history of pressing the pendant throughout the day. On 01/10/2022, LPA observed the pendant was cleared when R1 pressed the pendant on 12/18/2021 through 12/20/2021. However, 1 of 4 residents stated staff did not respond to resident's call. LPA is unable to review all pendant history for the month of December due to the system saving information for only 30 days. Based on interview, R1 moved out on 12/20/2021.

Facility staff did not ensure that diabetic resident was fed timely.

On 01/10/2022, LPA collected and reviewed R1's room service slips dated 12/01/2021 to 12/11/2021. Based on documentation, R1 was fed for breakfast, lunch, and dinner daily. Based on resident interviews, 3 of 4 residents stated facility staff ensures residents are fed timely. Based on staff interviews, 4 of 4 staff stated all residents are fed in a timely manner. However, 1 of 4 residents stated staff does not feed resident in a timely manner. Based on S1's interview, the room service slips are not used everyday. The room service slips are used for charging purposes, not tracking. LPA was unable to verify the remaining times R1 received her food.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited during visit. Exit interview conducted with Executive Director and a copy of report given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022

LIC9099 (FAS) - (06/04)

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