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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 10/12/2022
Date Signed: 10/12/2022 06:10:39 PM

Document Has Been Signed on 10/12/2022 06:10 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
CCLD Regional Office, 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: DATE:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Margaret TIME COMPLETED:
04:15 PM
NARRATIVE
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On 10/12/22, Licensed Program Analyst (LPA) R. Campbell arrived at Brookdale Kettlemen at approximately 1:00 pm to conduct a case management visit regarding an incident submitted to CCLD on 07/17/22. LPA spoke with Med Tech Delma De la Pena and explained the purpose of the visit.

Based on incident report, Med Tech #1(M1) reported that a medication error occurred on 07/17/22 . During change of shift, M1 was counting narcotics and realized Resident #1(R1) had not been given a full dose. R1 was to receive a 7.5mg of Methadone orally at 9 am but instead was only given 5 mg. R1 did not have any signs of distress or complaints of pain. R1's physician and family members were made aware of incident. Also on 08/15/22 facility reported that Resident #2 (R2) missed her dosage of Ativan and Tramadol as well and a dose of Tramadol 50 mg was missing for Resident #3(R3) .

Based on a review of R1’s incident that occurred on 07/17/22, R2’s incident report from 08/15/22, R3's incident report from 08/20/22 and their Medication Logs, medication was not provided or was provided incorrectly in error.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview with Executive Director. Appeal rights and a copy of report was given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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 10/12/2022 06:10 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/12/2022 at 05:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE KETTLEMAN LANE
FACILITY NUMBER: 397005466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited
CCR
87465(a)(4)

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87465(a)(4)Incidental Medical and Dental Care …The plan shall encourage routine medical and dental care … (4) The licensee shall assist residents with self-administered medications ....
This requirement is not met as evidenced by
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Licensee will require that med-techs undergo training on following medication orders. Licensee will provide proof of training by POC date.
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Based on observation, interview and record review, medication was missed on 08/15/22 and given incorrectly on 07/17/22 and 08/20/22 which poses a potential Health, Safety or Personal Rights risk to persons in care.
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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 King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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