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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 02/16/2022
Date Signed: 02/16/2022 02:11:51 PM


Document Has Been Signed on 02/16/2022 02:11 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: 41DATE:
02/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mary Margaret Chappell, Executive DirectorTIME COMPLETED:
02:25 PM
NARRATIVE
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On 02/16/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 01/29/2022. LPA spoke with Executive Director(ED), Mary Margaret Chappell and explained the purpose of the visit.

Based on incident report, Staff #1 (S1) reported that a medication error had occurred on 01/24/2022. Methadone 2.5mg was due to be administered at 10:00PM and was administered in error at 8:00PM by Staff #2 (S2) after medication time was changed to 10:00PM resulting in the medication being administered twice. Based on documentation and interview, R1's primary care physician, Vitas hopsice agency, and R1's family member was notified on 01/24/2022. No adverse reaction or increased pain noted. Based on Staff #3 (S3), S2 was moved from Med Tech to care staff until additional medication training was completed. S3 stated, S2 no longer works at the facility.

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 given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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 02/16/2022 02:11 PM - 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
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: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2022
Section Cited

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87465(c)(2): Incidental Medical and Dental Care:(c) ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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Based on documentation, Facility did not comply with the section cited in 87465(c)(2). Based on documentation, there was a medication error with R1, resulting in R1 receiving medication twice. This poses a potential health and safety risks to clients 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: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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