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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 10/25/2023
Date Signed: 10/26/2023 11:46:36 AM


Document Has Been Signed on 10/26/2023 11:46 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 41DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nicole BaconTIME COMPLETED:
12:00 PM
NARRATIVE
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On 10/26/2023 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit to follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with the executive director, and explained the purpose of today’s visit.

During the course of the department’s investigation, Interviews were conducted, and records reviewed. Interviews and records review conclude, The Licensee failed to ensure a sufficient provision to aid in fall prevention of R1 after R1 sustained multiple falls over a seven month period which led to injury of R1. On October 19th, 2023, the Department concluded the investigation and substantiated the findings.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.

Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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 10/26/2023 11:46 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/30/2023
Section Cited
HSC
1569.312(a)

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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by:
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Facility Administrator agrees to develop a plan and conduct training for all staff by POC date 10/30/2023 on appropriate intervention to aid in care and supervision to prevent injury. Facility will email LPa the signed sheet of training compleated by 11/10/2023.
Kesha.lewis@dss.ca.gov

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Based on record reviews and interviews, R1 sustained multiple falls over a period of seven month time frame without the Licensee ensuring appropriate intervention to aid in R1’s care and supervision resulting in injury. This posed an immediate risk to residents health, safety, and resident rights.
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Request Denied
Type A
10/27/2023
Section Cited
CCR87463(a)(3)

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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Licensee shall provide a statement of acknowledgement that appraisals are conducted on an ongoing basis by the POC date.

Kesha.lewis@dss.ca.gov
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Based on records review there was no updated needs and services plane done for R1 after falling multiple times. This posed an immediate risk to residents health, safety, and resident rights.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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