397005466-4-28-2023-27-AS-ECUL-CRHRPQ-20230504131215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005466
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:50:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Renee Campbell

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230306110047

FACILITY NAME:	BROOKDALE KETTLEMAN LANE		FACILITY NUMBER:	397005466
ADMINISTRATOR:	MARY MARGARET CHAPPELL		FACILITY TYPE:	740
ADDRESS:	2150 W KETTLEMAN LN		TELEPHONE:	(209) 333-8033
CITY:	LODI	STATE: CA	ZIP CODE:	95242
CAPACITY:	56	CENSUS: 38	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Mary Margaret Chappell, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Staff denied resident phone access
Staff denied resident visitors

INVESTIGATION FINDINGS:

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On 04/28/2023 at approximately 8:30 am, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Mary Margaret Chappell, Executive Director, and explained the purpose of the visit.
Based on Department interviews and record reviews, it was determined that resident1 (R1) had been placed under Conservatorship with San Joaquin County Public Guardian's Office after breaking her hip . R1 was then sent to the facility from the hospital. Initially, R1 had been able to call people and have visitors per witnesses and the complainant according to facility rules. This was changed by the Conservator, not the facility. R1 was barred from having visitors or making phone calls at the Conservators request.
Therefore, based on department record review, we have found that the complaint was unsubstantiated, meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur,
Exit interview completed and a copy of report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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