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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:55:13 PM

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: 42DATE:
01/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mary Margaret ChapelTIME COMPLETED:
12:46 PM
NARRATIVE
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LPA's T. White and M. Jensen arrived at this facility unannounced on 01/25/2022 at 12:30 PM to conduct a case management visit. LPA's T. White and M. Jensen met with Executive Director Mary Margaret Chapell and explained the purpose of the visit.

The purpose of the visit is to follow up on an incident report received on 12/29/2022. The report stated on 12/19/2022 at 2:30 PM, R1 walked up to R2 and pushed her. R2 became defensive and hit her back with an open hand causing a small scratch to R1's left side of face. R1 and R2 were separated and directed away from each other.

LPA's interviewed two staff members and reviewed R1 and R2's file documentation. Based upon interviews conducted on 01/25/2022 and facility records, the client has a history of aggressive behavior. LPA's discussed facility plan to prevent and mitigate further acts of aggression and plan proposed was appropriate. LPA's determined there has been no further incidents of concern to date.

Based on documentation, facility failed to meet the 7 day reporting requirement for Special incident reports. The incident occurred on 12/19/21 and the facility submitted the special incident report on 12/29/21.

The following deficiency was observed and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalty.


Exit interview conducted and appeal rights given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LANE
FACILITY NUMBER: 397005466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2022
Section Cited

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidence by
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based on observation facility did not comply with the section cited above in 87211(a)(1). LPA observed facility did not inform CCLD within 7 days of incident occurrence which poses a potential health and safety risk to residents 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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