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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003771
Report Date: 10/01/2025
Date Signed: 10/02/2025 08:53:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2025 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20250703090801
FACILITY NAME:BROOKDALE LODIFACILITY NUMBER:
397003771
ADMINISTRATOR:MARY MARGARET CHAPPELLFACILITY TYPE:
740
ADDRESS:2220 W. KETTLEMAN LANETELEPHONE:
(209) 367-8870
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:82CENSUS: 68DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:MARY MARGARET CHAPPELLTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Resident fell sustaining injuries due to staff neglect
Staff handled resident in a rough manner resulting in injuries
Staff are mismanaging residents medications
Staff did not ensure residents received medical care
Unqualified staff administered injections for residents
Unqualified staff providing wound care for residents
Staff did not prevent resident from engaging in inappropriate behaviors
Staff left residents in soiled bed
Staff did not safeguard residents personal belongings
INVESTIGATION FINDINGS:
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Staff did not ensure residents rooms were clean
Staff did not ensure the facility carpets were clean
Staff are inappropriately operating the Hoyer Lift

On 10/01/2025, Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced facility visit to continue the investagation for complaint for the above allegations. LPA met with Executive Director and explained the purpose of today's visit.

LPA Lewis requested and reviewed training records records, medication policy, and medical records for R1 also LPA Lewis interviewed two (2) staff members and one (1) resident. LPA lewis toured the facility during the visit and conducted a medication count.

see 9099C page
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20250703090801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE LODI
FACILITY NUMBER: 397003771
VISIT DATE: 10/01/2025
NARRATIVE
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Based on the records reviewed, interviews with staff and interviews with resident also the lack of identifying information in the complaint the allegations are found to be UNSUBSTANTIATED. although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

An exit interview was conducted, and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2