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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:34:59 PM


Document Has Been Signed on 06/12/2024 03:34 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: 42DATE:
06/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sara MackedsyTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted a case management visit as a result of the incident that took place on May 5, 2024. LPA met by the Health and Well-ness Director. and explained the purpose of today's visit.

The department received an incident report detailing that R1 had tarry stool and a decreased appetite. LPA obtained information from R1'S file including but not limited to R1'S physicians report, hospice notes and records and facility care notes. R1 was sent to the hospital on 5/4/2024 and later passed away on 05/10/2024. The department did not have a record of the facility reporting the death of R1 but the facility was able to provide a fax conformation that the LIC- 624A was faxed to the department on 05/16/2024 which is within the required reporting period.



Exit interview and 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)
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