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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:22:07 PM


Document Has Been Signed on 03/17/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:BROOKDALE LODIFACILITY NUMBER:
397003771
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2220 W. KETTLEMAN LANETELEPHONE:
(209) 367-8870
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:82CENSUS: 45DATE:
03/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Brittany Andrews, Assistant Executive DirectorTIME COMPLETED:
03:40 PM
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On 03/17/2022, Licensing Program Analyst (LPA) T. White conducted a case management visit regarding incident report that was submitted to CCLD on 02/23/2022. LPA spoke with Assistant Executive Director, Brittany Andrews and explained the purpose of the visit.

Based on incident report (SOC341), Staff #1 (S1) received an anonymous email regarding staff members verbally and physically abusing residents. S1 stated the facility interviewed 3 residents regarding incident and 3 of 3 residents stated they were not abused. S1 stated no further action was taken after interviews were completed.

LPA interviewed 3 staff members and 5 residents. Based on staff interviews, 3 of 3 staff members stated staff do not physically or verbally abuse residents. Based on resident interviews, 5 of 5 residents stated staff has not physically or verbally abused any residents.

No deficiencies cited during inspection.

Exit interview conducted with Assistant Executive Director and a copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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