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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:46:42 PM


Document Has Been Signed on 11/30/2023 03:46 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
11/30/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary Margaret Chappell TIME COMPLETED:
11:15 AM
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A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Administrator Mary Margaret Chappell as representative for the Licensee, Sara (Health and wellness Director) also on the meeting was Grace Ndomo( District Director) Kadi Berry (District Director), Andrew Lindner (Privacy Officer) and Joel Goldman (Attorney). The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.
Issues discussed related to the above include:

1. A plan ensuring appropriate supervision based on residents’ specific needs

2. Ensure completed staff training on the topic of care and supervision

3. Proper assessment of residents upon admission and reappraisals

4. Appropriate and timely communication resident physicians and family members And when to call 911

5. Ongoing medication training and reporting requirements



Exit interview conducted and report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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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: 11/30/2023
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A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Administrator Mary Margaret Chappell as representative for the Licensee, Sara (Health and wellness Director) also on the meeting was Grace Ndomo( District Director) Kadi Berry (District Director), Andrew Lindner (Privacy Officer) and Joel Goldman (Attorney). The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action.

Citations for the past 3 years - 5 A citations in areas of care and supervision, medication and Dental
Care, B citations in the past 3 years 1 in the area of reporting requirements and 1 citation in the area of furnishing documents on request on the department.

A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee.

On 10/25/23, Licensee was issued a citation under Title 22 section 87463(a)(3). The licensee did not provide care and supervision as necessary to meet the client’s needs. This resulted in resident receiving medical care one day post fall and hip fracture .

Issues discussed related to the above include:



1. A plan ensuring appropriate supervision based on residents’ specific needs

2. Ensure completed staff training on the topic of care and supervision

3. Proper assessment of residents upon admission and reappraisals

4. Appropriate and timely communication resident physicians and family members And when to call 911

5. Ongoing medication training and reporting requirements

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.
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SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 11/30/2023
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2. Ensure all residents diagnosed with Dementia receives an annual medical assessment as specified in Section 87458.
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.

In addition the Regional Office will continue with unannounced quarterly visits to monitor the above and overall compliance. Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking the following action(s):

Completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Codes if such action is deemed necessary by the Regional Manager.


In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.

Additional information provided by the licensee during the meeting included:

Brookdale Kettleman Lane has re-trained care staff on fall risk evaluations, universal fall precautions, post fall evaluation reports, when to call 9-1-1 , and ongoing assessment for change of conditions. Additionally, Brookdale district team has oversight including but not limited to; review of falls and change of condition. This is a collaboration with the District Director of Clinical Services and the Community. As of 11/24/2023


Brookdale Kettleman Lane recently re-trained Community Medication Technicians on medication management and skills competency, medication policy and procedure, and electronic medication administration system overview and have implemented additional oversight and review of new and changing orders.
They have implemented the following procedures and retrained staff specifically relating to toxic substances in our memory care neighborhood: securing personal care items and liquids, appropriate storage of chemicals, and when to call 9-1-1 and/or poison control; and a re-in service with staff took place on 1/18/2023. This re-in-service addressed the following: Proper storage of personal items, importance of hydration, and Personal items policy
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 11/30/2023
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Administrative Actions

The Regional Office has agreed to increased monitoring.

CCL will provide additional quarterly monitoring and facility inspections to verify improvement incompliance.

Failure to maintain substantial compliance outlined on LIC 9111 dated 11/30/2023 may result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action.



An exit interview was conducted via telephone and a copy of this report was sent electronically for signature.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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