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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 11/16/2020
Date Signed: 11/16/2020 10:55:24 AM

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 KETTLEMAN LANEFACILITY NUMBER:
397005466
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:56CENSUS: 39DATE:
11/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Via Telephone - Administrator Mary Margaret ChappellTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility on this day via telephone to conduct a Case Management - Incident Visit. This visit was conducted by telephone in lieu of a physical visit due to the current COVID-19 precautions. LPA spoke with Administrator (AD) Mary Margaret Chappell and explained the purpose of the visit.

On June 13, 2020 an Incident Report was submitted to Community Care Licensing (CCL) from Mary. Five medications were given to Resident (R1) by mistake, medications were intended for another resident at facility. On June 9, 2020 at approximately 4:40 PM, Medication Technician (MT) Staff (S1) was training MT- (S2) when S1 stepped away briefly to assist another resident. S1 stated that she told S2 to wait for her to return before assisting in administering any medications. S2 did not follow S1’s instructions and mistakenly gave all five of the medications to R1 instead of the correct resident.

Medications given to R1 were Depakote 125mg (behaviors), Lithium Carbonate 150mg (Bipolar Disorder), Risperdal 0.25mg (Agitation, and Senna 8.6mg (Stool Softener).

R1’s routine medications at 5:00 PM medication pass is Colace 100mg (Stool Softener), Coreg 6.25mg (Hypertension), Lipitor 20mg (High Cholesterol), Namenda 10mg (Dementia), and Seroquel 50mg (Anxiety/Behavior).

Staff notified Health and Wellness Director, Mary, R1’s family, R1's Primary Care Physician Confidential (C1) and Community Care Licensing.

Continued on 809-C
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 KETTLEMAN LANE
FACILITY NUMBER: 397005466
VISIT DATE: 11/16/2020
NARRATIVE
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Continued from 809

Physician C1 responded back to an order to: "Please monitor resident closely and notify MD; if gets worse send to Emergency.

Added information 6/17/2020 per LPA follow up request: On June 16, 2020

R1 on alert charting for three days by MT's and no adverse actions observed.
Additional one on one training on June 10, 2020 for MT- S2 with Health and Wellness Director. The training included six rights and using the correct approach in a memory care setting.
Result anticipated is a firm understanding of how S2 is to approach residents residing in Memory Care Unit.

LPA reviewed all documents provided, interviewed staff, Administrator, and Wellness Director. The staff, Administrator, and Wellness Director stated that medications were given to R1 based on the incident report submitted to CCL. Based on the documentation provided and acknowledgement of the facility, the incident regarding five medication errors given to R1 is SUBSTANTIATED. There was a preponderance of evidence to prove that the incident occurred as reported.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Mary and a copy of 809, 809-D were provided along with 811- Confidential names list, and appeal rights via email. An electronic email read receipt confirms receiving these documents.

If the cited deficiency is not corrected by the Plan of Correction Due Date; civil penalty may be assessed.

Exit interview held with Mary on today’s date.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 KETTLEMAN LANE
FACILITY NUMBER: 397005466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2020
Section Cited

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87465(c)(2) Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Based on LPA’s documentation reviewed and interviews R1 was administered the following medications in error: Depakote 125mg, Lithium Carbonate 150mg, Risperdal 0.25mg, and Senna 8.6mg. Licensee did not ensure the health and safety of residents which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3