<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:16:11 PM


Document Has Been Signed on 01/17/2023 03:16 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
SACRAMENTO AC/SC, 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: DATE:
01/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:MARY MARGARET CHAPPELLTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/17/23, Licensed Program Analysts (LPA'S) Kesha Lewis and Albert Johnson arrived at Brookdale Kettlemen at approximately 12:50 pm to conduct a case management visit regarding an incident submitted to CCLD on 11/25/22, 11/ 27/22, 12/ 07/22. LPA'S spoke with administer and explained the purpose of the visit.

Based on incident report received 11/25/2022, R1 was found in their room with a white substance on their lips it was later determined that the white was sunscreen, resident was unable to say whether the substance was ingested. Based on R1's 602 it was determined that they would be at risk if allowed direct access to personal grooming products.

Based on incident report on 11/23/22, R2 was breathing heavily and clearing their throat, they were sent to the ER and released later. Based on R2's 602 it was determined that she would be at risk if allowed direct access to personal grooming products.

Based on incident report received 12/07/2022 R3 was complaining of severe pain in their right hip after a fall that occurred on 12/06/22. Based on R3'S needs and service plan they are at higher rick for fall.

During records review it was found that R4 had a fall with injury.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview with Executive Director. Appeal rights and a copy of report was given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 2


Document Has Been Signed on 01/17/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2023
Section Cited

1
2
3
4
5
6
7
87705(g)(1) Care of Persons with Dementia. (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1)Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to submit a written plan ensuring that staff met the care and supervision needs of residents with Dementia. Plan of Correction is due on 01/18/2023
8
9
10
11
12
13
14
Based on records review The licensee did not ensure that staff met the care and supervision needs of R1 and R2 who had access to toxins in the facility when their 602 stated they would be at risk if allowed direct access to personal grooming products. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
01/27/2023
Section Cited

1
2
3
4
5
6
7
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to submit a written plan ensuring that staff met the care and supervision needs of residents with Dementia. Plan of Correction is due on 01/27/2023
8
9
10
11
12
13
14
Based on records review R3 and R4 had missing pre appraisal which did not allow facility or LPA'S to determine residents needs upon arrival. This poses an potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2