<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:35:41 AM


Document Has Been Signed on 06/12/2024 11:35 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 LANEFACILITY NUMBER:
397005466
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2150 W KETTLEMAN LNTELEPHONE:
(209) 333-8033
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:56CENSUS: 42DATE:
06/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sara MackedsyTIME COMPLETED:
12:00 PM
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
On 06/12/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.

LPA reviewed

1. Ensure completed staff training on the topic of care and supervision.
2. Proper assessment of residents upon admission and reappraisals.
3. Appropriate and timely communication resident physicians and family members And when to call 911.
4. Ongoing medication training and reporting requirements.


Based on random records review of training records. All training's are being kept up to date and have been completed. All training's were provide to LPA Lewis.

Exit interview conducted. Copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1