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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 06/08/2022
Date Signed: 06/08/2022 05:05:16 PM


Document Has Been Signed on 06/08/2022 05:05 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: 55DATE:
06/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Patricia OlveraTIME COMPLETED:
04:46 PM
NARRATIVE
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On 6-8-22 at 2:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident occurring on 3-13-22. LPA met with Patricia Olvera, Business Office Manager, and explained the purpose of the visit. Administrator Mary Margaret Chappell was made aware of LPA’s visit and purpose. LPA reviewed physician’s report and service plan for resident1 (R1). LPA also reviewed incident report dated 3-16-22 regarding R1. Additionally, LPA interviewed R1. LPA also tested emergency response testing system during visit. Based on record review and interview it was determined that on 3-13-22 at approximately 1:00am, R1 sustained a fall and was sent to the emergency room and returned with a femur fracture. Interview with R1 revealed R1 pushed emergency pendent after she attempted to get out of bed to use restroom, and staff responded to pendent within 5-10 minutes. Resident was then found on floor and was sent to emergency room by facility staff via 9-1-1 call. Interview with R1 also revealed appropriate staff are available to meet R1’s needs and response time to emergency pendant is adequate. An additional interview with R2 revealed appropriate staffing levels are consistent to meet needs.

LPA tested emergency pendent response time in the presence of Patricia Olvera and response was within 10 minutes. Review of physician’s report and service plan for R1 determine that both documents are updated to reflect R1’s current needs.

No deficiencies cited during today’s visit. An exit interview was held with Patricia Olvera and a copy of this report was left with Patricia.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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