397005466-8-4-2021-27-AS-LKIG-C628S5-20210818224545

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005466
Report Date: 08/04/2021
Date Signed: 08/04/2021 10:54:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/15/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210715114811

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: 42	DATE:	08/04/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Mary Margaret Chappell, Executive Director		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Facility staff are forging residents' medical assessments.

INVESTIGATION FINDINGS:

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On 08/04/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA White discussed the purpose of the visit and the elements of the allegation with Executive Director, Mary Margaret Chappell.

During the course of investigation, LPA collected medical assessments (LIC602) and Emergency Contact Information for 10 residents. LPA conducted interviews with 2 staff members and 3 of resident's responsible party's'. Based on staff interviews, S1 stated each Doctor's office has different procedures to completing residents medical assessments. S1 stated the facility, family, or medical assistant will fill out residents medical assessment. S1 stated the Doctor will review the filled out portion, review the document and sign. S1 stated the Doctor completes the diagnosis and medications on the medical assessment. Staff #2 (S2) stated the facility never touches documents after it is signed by the Doctor.

Report continues on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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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Control Number 27-AS-20210715114811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/04/2021

NARRATIVE

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LPA interviewed 3 of 10 residents responsible party. Based on interviews, R1's responsible party stated the she fills out the first page and the Physician fills out the remaining pages of R1's medical assessment. R2's responsible party stated the facility fills out the medical assessment and gives it to the Physician to sign. Based on interviews and documentation, there is insufficient information to determine the facility staff are forging residents' medical assessments.

Based on information obtained, LPA determined these allegations to be UNSUBSTANTIATED- means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. There are no citations being issued today.

Exit interview conducted with Executive Director and a copy of report given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC9099 (FAS) - (06/04)

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