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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 10/16/2024
Date Signed: 10/17/2024 11:49:51 AM

Document Has Been Signed on 10/17/2024 11:49 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BROOKDALE KETTLEMAN LANEFACILITY NUMBER:
397005466
ADMINISTRATOR/
DIRECTOR:		MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 56CENSUS: DATE:
10/16/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:MARY MARGARET CHAPPELLTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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A follow up Non-Compliance Conference (NCC) was conducted on this day in the Sacramento South Regional Office via Microsoft Teams. The purpose of this Follow up Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 11/30/2023. Present in the meeting was Regional Manager Stephenie Doub, Licensing Program Manager (LPM) LPM Liza King, Licensing Program Analyst (LPA) Kehsa Lewis, Licensee/Administrator MARY MARGARET CHAPPELL,Sara Mackedsy,Kadi Berry, Tabatha Clark, Amdrew Linder, Andrew Shepherd and Grace. and Valley Mountain Regional Center representatives. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process.

Since the last meeting on 11/30/2023, One new complaints has been filed and unsubstantiated against the facility, one Type A deficiencies has been cited. The facility was cited for the following issues, Maintenance and Operation.

During the meeting on 11/30/2023, the facility agreed to the following:

1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 12-04-23.
2. Ensure all residents diagnosed with Dementia receives an annual medical assessment as specified in Section 87458.

The Department will continue quarterly meetings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466
VISIT DATE: 09/30/2024
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3. Ensure all residents receive a revised needs and service appraisal at least once every 12 months, or upon a significant change in the resident’s condition, as defined by regulations, whichever occurs first.

4. Documented training to be maintained and available for review by the LPA upon request

5. Facility will provide training material and policy information by 12/04/2023.

6. Facility will look into TSP offered by CCL.

Exit interview and copy of report provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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