397005466-6-12-2024-27-AS-KLES-D66P8F-20240612110527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 06/11/2024
Date Signed: 06/12/2024 11:07:05 AM

Document Has Been Signed on 06/12/2024 11:07 AM - 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 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:	06/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sara Mackedsy		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPA) Kesha Lewis and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA and LPM were met by administrator. LPM explained the purpose of the visit to Administrator.

LPA ,LPM and health and well-ness director inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 56 bed facility with a current census of 42. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA pushed the call button in room five (5) the was no response from facility staff. LPA and also conducted the care tool. No bodies of water were observed at the facility.

Hot water temperature was measured at 107 F degrees Fahrenheit in residents bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. The average temperature was 107 F. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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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Document Has Been Signed on 06/12/2024 11:07 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/13/2024 Section Cited CCR 87303(i)(1)(A)	1 2 3 4 5 6 7	Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by LPA pushing call buttons in mulitple resident rooms. Room 5 the call system did not	1 2 3 4 5 6 7	Facility will submit a written plan of correction indicating the steps the facility takes to ensure regular testing of resident pendents and staff pagers to ensure they are operating as intended and staff receive notifications for assistance.
	8 9 10 11 12 13 14	notifiy of an alert from a resident's room and which poses an immediate health safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 06/11/2024

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LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. The signal systems in room five (5) was pushed by LPA and there was no response by facility staff. when Well-ness director checked the alert was not sent to care staff beepers. The maintenance director states the the call system is tested monthly by randomly choosing about six (6) rooms.

LPA observed, fire extinguishers inspected on 10/07/2023 the fixed system was inspected 04/17/24 there are current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Last fire drill was conducted on 06/10/2024 for NOC shift and 05/30/2024 for day shift.

LPA reviewed two (15) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.

LPM reviewed two (9) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.

Deficiencies are being cited during today visit see 809D page....

Exit interview held with staff and copies of reports and appeal rights left at conclusion of visit.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

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