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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005466
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:35:19 PM


Document Has Been Signed on 07/05/2022 03:35 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: 42DATE:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sara Mackedsy, Executive DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) R. Campbell and T. White conducted an unannounced Annual 1-Year Required visit on this date. LPAs met and toured with Executive Director Sara Mackedsy. The facility’s fire clearance was approved for 04/2014. Upon entry LPA was screened for COVID symptoms, a sign in/sign out procedure was observed as well as facility staff wearing masks.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

The last fire drill occurred on 06/26/2022. Fire extinguisher was last serviced on October 26, 2021. First aid kit was observed to be complete.

LPA reviewed 5 out of 5 staff files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs. 5 of 5 staff have current first aid training but signed employee rights were not found in employee files. One staff did not have a health screening. The facility serves residents with dementia and staff have received the necessary training hours specific to dementia. LPA reviewed 5 of 5 residents’ files and a sample of residents’ medication logs were reviewed.

LPAs observed the following deficiency:
- During record review, LPAs observed 1 of 5 staff not associated to the facility.
- During record review, LPAs observed no signed employee rights forms in 5 of 5 staff personnel file.
-During record review, 1 out of the 5 staff did not have a health screening.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 07/05/2022 03:35 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: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/19/2022
Section Cited

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(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This regulation was not followed as observed in the lack of sighed Employee RIghts forms in Personnel Files.
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Based on record review, licensee did not comply with section cited above in 87412(g). LPA observed 5 of 5 staff files did not have employee rights on file which poses as a potential health and safety risks 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: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/05/2022 03:35 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: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance. This requirement was not met as evidence by:
Type B
07/06/2022
Section Cited

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Based on record review, licensee did not comply with section cited above in 87355 (e)(2). LPA observed S1 is not associated to the facility which poses as an immediate health and safety risks 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: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4