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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:00:14 PM

Unsubstantiated


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
04/28/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220428133810
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: 62DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Mary Margaret ChappellTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff assaulted resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6-22-22 at 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegation listed above. LPA met with Administrator Mary Margaret Chappell and explained the purpose of the visit. During this investigation, On 6-8-22, LPA interviewed staff1 (S1), S2, and S3. LPA also interviewed Resident2 (R2), R3, and R4. On 6-8-22, LPA also interviewed Administrator on duty at time of alleged incident. Additionally, LPA reviewed facility file documentation including pre-admission appraisal for R1, physician’s report for R1, physician communication note for R1, staffing schedule, and police report dated 4-27-22.
Based on interviews and record reviews conducted, it was determined that Resident1 (R1) stated an allegation of being slapped in the face and punched in the back on 4-27-22 by a caregiver. Interviews conducted and records reviewed revealed no witnesses to said allegation or outstanding visible injuries noted. A police report dated 4-28-22 revealed no visible injuries and no witnesses to alleged incident noted.
As a result, it is determined that there is not a preponderance of evidence to prove this allegation occurred, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Mary Margaret Chappell and a copy of this report was left with Mary. Appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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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