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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:37:29 PM


Document Has Been Signed on 03/01/2023 03:37 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 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:
03/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Gretchen MonaresTIME COMPLETED:
04:00 PM
NARRATIVE
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On 3-1-23 at 1:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incidents which occurred on 1-9-23 and 1-10-23. LPA met with Health and Wellness Director Gretchen Monares and explained the purpose of the visit. LPA reviewed incident reports dated 1-15-23 and facility file documentation for resident1 (R1) and R2. LPA also conducted health and safety facility tour as part of this case management. Additionally, LPA interviewed Health and Wellness Director

On 1-15-23, facility reported that on 1-9-23, R1 was not assisted with administering medication Methadone 5mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed medication was prescribed with start date of 11-17-22.

On 1-15-23, facility reported that on 1-10-23, R2 was not assisted with administering medication Depakote 250mg (milligram) as prescribed by Physician. Medication orders reviewed confirmed Physician orders for medication are dated as of 6/30/22.

LPA conducted facility tour with health and wellness director. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included 2 med techs, 3 caregivers, 3 kitchen staff, 4 management staff, and 1 receptionist. Fire extinguisher was full charged and dated 10-12-22. Room temperature was 71*F. Facility is a secured, exclusive memory care unit. Egress door alarms are placed on doors and functioning properly. There is a lobby area leading to a secured, alarmed door leading to memory care unit. Smoke alarms and carbon detectors are functioning properly. Current census is 39. No obstructions to fire exits noted during today's tour. As a result of today's case management visit, deficiencies are cited under Title 22, Division 6, Chapter 8. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within 12-month period. An exit interview was conducted with Gretchen Monares and a copy of this report was left with Gretchen. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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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Document Has Been Signed on 03/01/2023 03:37 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
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2023
Section Cited

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Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on proper assistance with self-administration of medication including but not limited to: Following physician orders. Training date to be submitted to LPA by POC due date.
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Based on interview and record review,Licensee did not comply with section cited above in that R1 and R2 did not receive medication as prescribed by physician due to facility staff error. This posed an immediate health and safety risk ti residents in care.
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Training to be completed no later than 2 weeks from date of citation issuance. Proof of completed training to be submitted to LPA prior to citation clearance.

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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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