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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 07/20/2021
Date Signed: 07/21/2021 07:38:01 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: 41DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mary Margaret, Executive DirectorTIME COMPLETED:
11:45 AM
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On 07/20/2021 at 8:35am, Licensing Program Analyst (LPA) T. White spoke with facility staff, regarding facility risk assessment questions. Facility staff confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:50am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Executive Director, Mary Margaret Chappell and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 56 non-ambulatory residents which 15 may be on hospice.

LPA toured the facility including but not limited to apartments, bathrooms, kitchen, common area, backyard and courtyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 109.9, 107.2 and 106.2 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPA observed smoke detector is interconnected with the fire department. LPA observed carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on October 28, 2020. Emergency Disaster Plan was last posted on 06/22/2021. First aid kit was observed to be complete. Fire drill was last conducted on 07/04/2021. LPA observed mitigation plan is complete.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/27/2021:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
No deficiencies cited. Exit interview conducted with 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: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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