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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 03/14/2023
Date Signed: 03/14/2023 05:27:37 PM


Document Has Been Signed on 03/14/2023 05:27 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: 40DATE:
03/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Business Manager, Patricia OlveraTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Renee Campbell  arrived to the facility unannounced on 03/14/23 at approximately 11:00 am to conduct case management visit to follow up on various incident reports received. LPA met with Business Manager, Patricia Olvera and Associate Executive Director Nicole Bacon and explained the purpose of the visit.
LPA reviewed documents and verified proper protocols were followed.  The following residents received immediate medical care and their respective responsible parties were notified.

Resident  (R1) had an unwitnessed fall, experienced vaginal bleeding and was taken to the hospital for tests and released with no new discharge orders. No diagnosis was found.
Residents 2 to Resident 13 (R2 to R13) experienced nausea and vomiting and had to go to the hospital to receive medical care.  Per the Business Manager, two residents tested positive for Norovirus but by that time, the rest of the residents had recovered.  All residents returned to baseline and remain in care at the facility.      
Resident 13 (R13) experienced edema.  He refused transport to the hospital until his daughter arrived and drove him herself.  He also returned to the facility.

Business Manager, Patricia Olvera and Associate Executive Director Nicole Bacon agreed to provide supporting documents by 03/15/23 at the latest.
Exit Interview and copy of report provided.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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