Brookdale Kettleman Lane

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst, Kesha Lewis arrived on 08/24/2026 for an unannounced inspection to follow up on an incident reported by the facility in which a resident had fallen resulting in a hip fracture. LPA met with MARY MARGARET CHAPPELL and explained the purpose of the visit. On October 25, 2023, LPA conducted a case management investigation due to a facility reported incident which described resident (R1) complaining of severe pain from a fall that occurred the day prior. On October 25, 2023, the Department concluded an investigation, and the licensee was cited for a violation of California Code of Regulations (CCR) Title 22, section 87463(a)(3) Reappraisals. At the time of the case management visit on October 25, 2023, the licensee was informed that a civil penalty may be assessed based on Health and Safety Code section 1569.49. The Department has concluded an analysis and determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code section 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” The Licensee failed to ensure timely medical care when R1 sustained a hip fracture from an unwitnessed fall, expressed pain to staff, and was not sent to the hospital until the following day. Today, 08/24/2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. MARY MARGARET CHAPPELL and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 24, 2026

Allegation investigated: Staff are not reporting incidents to authorized representatives Due to lack of staff, residents are left unattended Staff are not assisting residents due to lack of staff

On 07/24/2026, Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced facility visit to deliver findings for complaint for the above allegations. LPA met with Health and wellness Director and explained the purpose of today's visit. Based on the records reviewed that show there is 4 care givers and two medication tech and LVN on call at night and during the day there is no less then 5 care givers one LVN and two med techs, and interviews with authorized representatives that confirm they were notified of an insident with their family member. The allegations above are UNSUBSTANTIATED. A finding of unsubstaniated means 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2026 · control 27-AS-20260511154015

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Jun 25, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by staff and administrator. LPA explained the purpose of the visit to Administrator and staff. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 56 bed facility with a current census of 45. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility. Hot water temperature was measured at 108 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers inspected on 10/17/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed two (8) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed two (8) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with staff and copies of reports left at conclusion of visit.the state’s words, verbatim · CDSS document, Jun 25, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Apr 7, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Facility does not employ adequate staff to meet the residents' needs. Residents do not received assistance from staff in a timely manner. Residents are left in soiled for extended period of time.

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to open a complaint for the above allegations. LPA was greeted by staff and explained the reason for the visit. Based on the information provided by the reporting party and the actual rooms in the facility this can not be a correct facility. There is a discrepancy in the room numbers provided in the complaint to the rooms that are in the facility. LPA did not observe a preponderance of evidence standard therefore the allegations are UNFOUNDED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. “This agency has investigated the complaint alleging the above mentioned allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.” An exit interview was held, and a copy of this report was given. Unfoundedthe state’s words, verbatim · CDSS document, Oct 7, 2025 · control 27-AS-20251003102613

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Oct 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by administrator. LPA explained the purpose of the visit to Administrator and staff. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 56 bed facility with a current census of 44. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the infection control domain tool. No bodies of water were observed at the facility. Hot water temperature was measured at 107 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers inspected on 10/17/2024 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed seven (7) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed seven (7) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with staff and copies of reports left at conclusion of visit.the state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident reports received dated 3/31/2025 for incident that happened in on 03/31/2025. LPA explained purpose of visit to the administrator. The incident reports were regarding a staff member threatening and resident (R1). LPA reviewed internal investigation. S1 was suspended on 3/31/2025 terminated and has not returned to the facility after 04/04/2025. All reporting was done on time and to the required departments. Per California Code of Regulations, Title 22 NO deficiencies were observed and are being cited during today's case management inspection. An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident reports received dated 2/11/2025 for incident that happened in on 02/05/2025. LPA explained purpose of visit to the administrator. The incident reports were regarding a witnessed fall for R1 that resulted in a left hip fracture. LPA reviewed incidents report and Resident records. Facility provided R1'S Physicians report (LIC 602), preplacement, care notes, hospice records, MARS and admissions agreement. R1 has not returned to the facility after 02/05/2025. All reporting was done on time and to the required departments. This matter is still under investigation. Per California Code of Regulations, Title 22 NO deficiencies were observed and are being cited during today's case management inspection. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Case Management - Legal/Non-compliance

On 12/17/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Office

A follow up Non-Compliance Conference (NCC) was conducted on this day in the Sacramento South Regional Office via Microsoft Teams. The purpose of this Follow up Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 11/30/2023. Present in the meeting was Regional Manager Stephenie Doub, Licensing Program Manager (LPM) LPM Liza King, Licensing Program Analyst (LPA) Kehsa Lewis, Licensee/Administrator MARY MARGARET CHAPPELL,Sara Mackedsy,Kadi Berry, Tabatha Clark, Amdrew Linder, Andrew Shepherd and Grace. and Valley Mountain Regional Center representatives. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. Since the last meeting on 11/30/2023, One new complaints has been filed and unsubstantiated against the facility, one Type A deficiencies has been cited. The facility was cited for the following issues, Maintenance and Operation. During the meeting on 11/30/2023, the facility agreed to the following: 1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 12-04-23. 2. Ensure all residents diagnosed with Dementia receives an annual medical assessment as specified in Section 87458. The Department will continue quarterly meetings. 3. Ensure all residents receive a revised needs and service appraisal at least once every 12 months, or upon a significant change in the resident’s condition, as defined by regulations, whichever occurs first. 4. Documented training to be maintained and available for review by the LPA upon request 5. Facility will provide training material and policy information by 12/04/2023. 6. Facility will look into TSP offered by CCL. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Oct 16, 2024

Type of visit: Case Management - Other

On 09/23/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed and copies provided. 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Case Management - Other

On 06/12/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. All training's are being kept up to date and have been completed. All training's were provide to LPA Lewis. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis conducted a case management visit as a result of the incident that took place on May 5, 2024. LPA met by the Health and Well-ness Director. and explained the purpose of today's visit. The department received an incident report detailing that R1 had tarry stool and a decreased appetite. LPA obtained information from R1'S file including but not limited to R1'S physicians report, hospice notes and records and facility care notes. R1 was sent to the hospital on 5/4/2024 and later passed away on 05/10/2024. The department did not have a record of the facility reporting the death of R1 but the facility was able to provide a fax conformation that the LIC- 624A was faxed to the department on 05/16/2024 which is within the required reporting period. Exit interview and copy of report given.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kesha Lewis and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA and LPM were met by administrator. LPM explained the purpose of the visit to Administrator. LPA ,LPM and health and well-ness director inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 56 bed facility with a current census of 42. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA pushed the call button in room five (5) the was no response from facility staff. LPA and also conducted the care tool. No bodies of water were observed at the facility. Hot water temperature was measured at 107 F degrees Fahrenheit in residents bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. The average temperature was 107 F. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. The signal systems in room five (5) was pushed by LPA and there was no response by facility staff. when Well-ness director checked the alert was not sent to care staff beepers. The maintenance director states the the call system is tested monthly by randomly choosing about six (6) rooms. LPA observed, fire extinguishers inspected on 10/07/2023 the fixed system was inspected 04/17/24 there are current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Last fire drill was conducted on 06/10/2024 for NOC shift and 05/30/2024 for day shift. LPA reviewed two (15) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPM reviewed two (9) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. Deficiencies are being cited during today visit see 809D page.... Exit interview held with staff and copies of reports and appeal rights left at conclusion of visit.the state’s words, verbatim · CDSS document, Jun 11, 2024

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Jun 13, 2024

Maintenance and Operation: Facilities shall have signal systems which shall meet the following criteria: Operate from each resident's living unit. This requirement was not met as evidenced by LPA pushing call buttons in mulitple resident rooms. Room 5 the call system did not notifiy of an alert from a resident's room and which poses an immediate health safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2024

Allegation investigated: Personal Rights Personal Rights Personal Rights Personal Rights

On 04/16/2024 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver complaint findings for the allegations noted above. the health and wellness dirsctor, and explained the purpose of the visit. LPA attmepted to reach RP multiple times by phone and email, RP responded to emails but would not diclose the residents name the complaint was made for. Therefore, based on review of the facility, it is found that the complaint was unsubstantiated, meaning, 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. See 9099C. Unsubstantiated LPA conducted facility tour with health and wellness director. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Staffing levels included 2 med techs, 3 caregivers, 8 management staff, and 1 receptionist. Fire extinguisher was full charged and current. Room temperature was 71*F. Facility is a secured, exclusive memory care unit. Egress door alarms are placed on doors and functioning properly. There is a lobby area leading to a secured, alarmed door leading to memory care unit. Smoke alarms and carbon detectors are functioning properly. Current census is 44 . No obstructions to fire exits noted during today's tour. Exit interview completed and a copy of report provided.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 27-AS-20240319104407

Type of visit: Case Management - Other

On 03/30/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit. LPA reviewed 1. Ensure completed staff training on the topic of care and supervision. 2. Proper assessment of residents upon admission and reappraisals. 3. Appropriate and timely communication resident physicians and family members And when to call 911. 4. Ongoing medication training and reporting requirements. Based on random records review of training records. all training's are being kept up to date and have been completed. All training's were emailed to LPA on 03/20/24. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Mar 20, 2024

Allegation investigated: Staff do not properly store food

On 12/14/23, Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to facility at approximately 12:45 pm. LPA Campbell discussed the purpose of the visit and the elements of the allegation with Assistant Executive Director Nicole Bacon. Regarding the allegation that staff do not properly store food, prepared desserts were observed by LPA Campbell to be stored uncovered in the refrigerator. Based on LPA’s observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. An exit interview was conducted, and copies of the report and appeal rights left. Substantiatedthe state’s words, verbatim · CDSS document, Dec 14, 2023 · control 27-AS-20230824115015

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Dec 29, 2023

87555(b)(23) All readily perishable foods...shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by Based on observation, food was stored in the refrigerator uncovered.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee agrees to conduct an in-service staff training on food cycling and food dating. Licensee agrees to send LPA Campbell a copy of a sign-in sheet for this training by the POC due date. Renee.cambell@dss.ca.gov

Type of visit: Office

A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Administrator Mary Margaret Chappell as representative for the Licensee, Sara (Health and wellness Director) also on the meeting was Grace Ndomo( District Director) Kadi Berry (District Director), Andrew Lindner (Privacy Officer) and Joel Goldman (Attorney). The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action. Issues discussed related to the above include: 1. A plan ensuring appropriate supervision based on residents’ specific needs 2. Ensure completed staff training on the topic of care and supervision 3. Proper assessment of residents upon admission and reappraisals 4. Appropriate and timely communication resident physicians and family members And when to call 911 5. Ongoing medication training and reporting requirements Exit interview conducted and report provided. A Noncompliance Conference (NCC) was conducted today, via Microsoft Teams. The purpose of the NCC was to discuss the facilities substantiated non compliance. Present at today’s NCC were the Regional Office Manager Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPA) Kesha Lewis and Kathryn Thomas, Long term Care Ombudsman and Administrator Mary Margaret Chappell as representative for the Licensee, Sara (Health and wellness Director) also on the meeting was Grace Ndomo( District Director) Kadi Berry (District Director), Andrew Lindner (Privacy Officer) and Joel Goldman (Attorney). The administrative process was explained during this meeting and Licensee was informed that further citations may result in Administrative Action. Citations for the past 3 years - 5 A citations in areas of care and supervision, medication and Dental Care, B citations in the past 3 years 1 in the area of reporting requirements and 1 citation in the area of furnishing documents on request on the department. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. On 10/25/23, Licensee was issued a citation under Title 22 section 87463(a)(3). The licensee did not provide care and supervision as necessary to meet the client’s needs. This resulted in resident receiving medical care one day post fall and hip fracture . Issues discussed related to the above include: 1. A plan ensuring appropriate supervision based on residents’ specific needs 2. Ensure completed staff training on the topic of care and supervision 3. Proper assessment of residents upon admission and reappraisals 4. Appropriate and timely communication resident physicians and family members And when to call 911 5. Ongoing medication training and reporting requirements During the meeting on 11/30/2023, the facility agreed to the following: 1. Submission of LIC 500 Personnel Summary for supervisory changes facility to include Administrator presence with no less than 40 hours per week by 12-04-23. . 2. Ensure all residents diagnosed with Dementia receives an annual medical assessment as specified in Section 87458. 3. Ensure all residents receive a revised needs and service appraisal at least once every 12 months, or upon a significant change in the resident’s condition, as defined by regulations, whichever occurs first. 4. Documented training to be maintained and available for review by the LPA upon request 5. Facility will provide training material and policy information by 12/04/2023. 6. Facility will look into TSP offered by CCL. In addition the Regional Office will continue with unannounced quarterly visits to monitor the above and overall compliance. Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking the following action(s): Completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Codes if such action is deemed necessary by the Regional Manager. In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action. Additional information provided by the licensee during the meeting included: Brookdale Kettleman Lane has re-trained care staff on fall risk evaluations, universal fall precautions, post fall evaluation reports, when to call 9-1-1 , and ongoing assessment for change of conditions. Additionally, Brookdale district team has oversight including but not limited to; review of falls and change of condition. This is a collaboration with the District Director of Clinical Services and the Community. As of 11/24/2023 Brookdale Kettleman Lane recently re-trained Community Medication Technicians on medication management and skills competency, medication policy and procedure, and electronic medication administration system overview and have implemented additional oversight and review of new and changing orders. They have implemented the following procedures and retrained staff specifically relating to toxic substances in our memory care neighborhood: securing personal care items and liquids, appropriate storage of chemicals, and when to call 9-1-1 and/or poison control; and a re-in service with staff took place on 1/18/2023. This re-in-service addressed the following: Proper storage of personal items, importance of hydration, and Personal items policy Administrative Actions The Regional Office has agreed to increased monitoring. CCL will provide additional quarterly monitoring and facility inspections to verify improvement incompliance. Failure to maintain substantial compliance outlined on LIC 9111 dated 11/30/2023 may result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. An exit interview was conducted via telephone and a copy of this report was sent electronically for signature.the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Case Management - Deficiencies

On 10/26/2023 Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit to follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with the executive director, and explained the purpose of today’s visit. During the course of the department’s investigation, Interviews were conducted, and records reviewed. Interviews and records review conclude, The Licensee failed to ensure a sufficient provision to aid in fall prevention of R1 after R1 sustained multiple falls over a seven month period which led to injury of R1. On October 19th, 2023, the Department concluded the investigation and substantiated the findings. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 25, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Oct 30, 2023

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on record reviews and interviews, R1 sustained multiple falls over a period of seven month time frame without the Licensee ensuring appropriate intervention to aid in R1’s care and supervision resulting in injury. This posed an immediate risk to residents health, safety, and resident rights.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Facility Administrator agrees to develop a plan and conduct training for all staff by POC date 10/30/2023 on appropriate intervention to aid in care and supervision to prevent injury. Facility will email LPa the signed sheet of training compleated by 11/10/2023. Kesha.lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(a)(3) · Plan of correction due date: Oct 27, 2023

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. Based on records review there was no updated needs and services plane done for R1 after falling multiple times. This posed an immediate risk to residents health, safety, and resident rights.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: Licensee shall provide a statement of acknowledgement that appraisals are conducted on an ongoing basis by the POC date. Kesha.lewis@dss.ca.gov