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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003771
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:23:10 PM


Document Has Been Signed on 08/17/2022 03:23 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: DATE:
08/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mary Margaret ChappellTIME COMPLETED:
03:30 PM
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On 8-17-22 at 2:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to open a case management related to incident reports dated 7-8-22, 7-9-22, and 7-11-22. LPAs met with Administrator Mary Margaret Chappell and explained the purpose of the visit. LPAs also reviewed facility file documentation including progress notes for resident1 (R1), Physician's report for R1, Personalized service plan for R1, and staffing schedule for July 2022. LPAs also interviewed Administrator and Staff1 (S1). Based on records reviews and interviews, it was determined that R1 sustained falls on the three dates noted above and sustained a head injury as a result.

Based on additional record reviews and interviews, it was determined that facility had implemented fall prevention precautions for R1 and increased staff monitoring of R1 on 7-11-22 due to recent falls. R1 was place on hospice on 7-12-22 and expired on approximately 7-22-22. Staffing schedule indicates adequate staffing levels on dates of reported falls. LPAs conducted check of facility's emergency pendant system and determined that system is functioning adequately.

As a result of today's case management visit, no deficiencies are issued. An exit interview was conducted with Mary Margaret Chappell and a copy of this report was provided to Mary.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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