397005466-4-16-2024-27-AS-KHOS-D4LNA3-20240423101652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005466
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:24:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2024 and conducted by Evaluator Kesha Lewis

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240319104407

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: 44	DATE:	04/16/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	MARY MARGARET CHAPPELL		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights
Personal Rights
Personal Rights
Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/16/2024 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver complaint findings for the allegations noted above. the health and wellness dirsctor, and explained the purpose of the visit.

LPA attmepted to reach RP multiple times by phone and email, RP responded to emails but would not diclose the residents name the complaint was made for. Therefore, based on review of the facility, it is 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.

See 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 27-AS-20240319104407

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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, 8 management staff, and 1 receptionist. Fire extinguisher was full charged and current. 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 44 . No obstructions to fire exits noted during today's tour.

Exit interview completed and a copy of report provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2