Brookdale Lodi

Allegation investigated: Licensee does not ensure staff have required training Staff speak inappropriately to residents

On 07/26/2026, Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced facility visit to deliver findings for complaint for the above allegations. LPA met with Mary Margaret Chappell and explained the purpose of today's visit. Based on the records reviewed, staff and resident interviews three (3) out of three (3) staff confiremed the training they recieved and four (4) out of four (4) residents confirmed they had not been spoken to or heard any stff speak to residents inappropriately. 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 27, 2026 · control 27-AS-20260511092801

Allegation investigated: Staff did not prevent resident(s) from developing a pressure injury Staff do not ensure resident receives medical attention in a timely manner Staff administer medication without a doctor's prescription Staff mismanage residents medication Staff do not ensure that resident is assisted with glucose testing Staff places residents on hospice care without residents consent

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 wellness Director and explained the purpose of today's visit. Based on the records reviewed, staff interviews along with facility tour and tour of the medication room. 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-20260527133538

Allegation investigated: Staff does not provide resident’s meals in a timely manner. Staff does not refill resident(s) medication prescription in a timely manner.

On 11/19/2025, Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced facility visit to continue the investigation for complaint for the above allegations. LPA met with Executive Director and explained the purpose of today's visit. Based on the records reviewed, interviews with staff and interviews with resident the resident chose when they wanted to have their meals, the facility has an all-day meal availability policy therefore the complaint the allegation is 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 19, 2025 · control 27-AS-20250723160851

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 27-AS-20250703090801

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 joined 10 minutes later. 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 82 bed facility with a current census of 68. There is entry door is leading to the common area, dining room 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 110 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 05/29/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed fifteen (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. LPA reviewed fifteen (15) 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, Oct 1, 2025

Allegation investigated: Staff are mismanaging residents medication Staff are not preventing resident from enagaging in inappropriate behaviors

On 05/13/2025, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director Nicole Bacon and explained the purpose of today's visit. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that the staff mismanaged resident’s medication or that Staff are not preventing resident from engaging in inappropriate behaviors. Both the doctor’s directives and the client’s requests were followed as required. Staff had appropriate training in deescalating behaviors. Due to the above noted information, 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 13, 2025 · control 27-AS-20250213113306

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on a incident report that was received 01/06/25. LPA explained purpose of visit to Administrator. The incident report was regarding a resident's (R1) death. On 01/01/2025, Resident 1 (R1) sustained an unwitnessed fall in her apartment and was timely taken to San Joaquin General Hospital where they was diagnosed with a subdural hematoma. File review records indicate R1 was a fall risk when they moved into the facility in May 2024 due to a fall that was sustained prior to moving into Brookdale Lodi. Staff report that within months of moving into Brookdale Lodi, R1’S physical health improved, and they did not show any signs that would support they were a fall risk resident. R1 was independent and did not require frequent checks. Prior to the fall on 01/01/2025, R1 sustained one minor fall in June 2024, but it did not result in serious injury. No specific fall measures were put in place at that time as R1 was independent and did not show indicators of being a fall risk. This investigation concludes that there is insufficient evidence to support that the fall/injury was as a result of staff neglect/lack of care. Exit interview and copy of report given.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on a incident report that was received 01/06/25. LPA explained purpose of visit to Administrator. The incident report was regarding a resident's (R1) death. The facility will gather and provide to LPA the care notes from May to January medication administration records for October to January and any incident reports for R1 in the last 12 months. The facility will also provided a copy of R1'S , 602 (Physician's report) and needs and services plan. This matter is still under investigation. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Case Management - Incident

On 12/22/2024, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit LPA met with ED MARY MARGARET CHAPPELL, and explained the purpose of the visit. The purpose of this visit was to follow up on an incident report that was received by the Department on 10/26/2024. Current Census was 78. Based on the incident report received by the department on 10/31/2024, it was reported by this facility that on 10/26/2024 R1 was given the incorrect dose of medication. Based on interviews conducted it was learned that around the SIR was typed incorrectly and that the dosage given was not as high as first reported to the department. The correct dose was to be 75 MG, first reported was that the dose given was 450 MG, but the actual dose given was 225 MG. Deficiencies are being cited during todays visit see 809D page....the state’s words, verbatim · CDSS document, Dec 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 18, 2024

87465 Incidental Medical and Dental Care (4) The licensee shall assist residents with administered medications as needed. This requirement was not met as evidenced by: Based on interviews and record review the facility did not administer medications as prescribed by a doctor which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Licensee agreed to complete a medication trainging with all staff focusing on rights of adminstration. Kesha.Lewis@dss.ca.gov

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 joined 30 minutes later. 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 82 bed facility with a current census of 79. 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 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 05/16/2024 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. Elevator certificate expires 04/16/2025. LPA reviewed fifteen (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. LPA reviewed fifteen (15) 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, Oct 15, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on a incident report that was received 2/7/24. LPA explained purpose of visit to Administrator. Resident is no longer at this facility. The incident report was regarding a resident receiving the same does of medication in the same day. The facility will gather and provide to LPA the hospice care notes from the follow up visit after the incident to the LPA by 3/29/2024. The facility will also provided a copy of R1'S , 602 (Physician's report) and needs and services plan. This matter is still under investigation. An exit interview was conducted and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 20, 2024

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 report received dated 02/03/2024 . LPA explained purpose of visit to the administrator. The incident report was regarding a resident unwitnessed fall. Facility provided and LPA reviewed R1'S physician's report (602), needs and services plan and the discharge paperwork from the hospital. All incidents were reported on time and to the correct departments. Per California Code of Regulations, Title 22 no deficiencies were observed or 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, Feb 13, 2024

Allegation investigated: Staff mismanage resident's medication

Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced on 12/14/23 at 11:30 AM to deliver complaint findings, LPA Renee Campbell met with Associate Executive Director and explained the purpose of the visit. Allegation #1: Staff mismanage resident’s medication. When interviewed, H1 stated that hospice had to ask the husband to step out so that staff could directly ask R1 if she wanted pain medication. Per H2, R1 asked for pain medication more “towards the end of her decline”. LPA Campbell observed that the Medication Administration Record (MAR) was completed correctly in regard to the doctor’s orders. S1 also explained how staff ensured R1 gave consent for pain management. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that the staff mismanaged resident’s medication. Both the doctor’s directives and the clients requests were followed as required. Due to the above noted information, 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, Dec 14, 2023 · control 27-AS-20230920111234

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: The Administrator is not available to attend to the management and administration of the facility.

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to continue investigation and deliver findings for the allegations noted above. LPA met with Administrator Mary Margaret Chappell and explained the purpose of the visit. LPA also conducted interviews with Administrator and S1 during today's visit and reviewed the most recent staff roster and LIC 500. Allegation #1: The Administrator is not available to attend to the management and administration of the facility. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that The Administrator is not available to attend to the management and administration of the facility. As a result, this allegation is UNSUBSTANTIATED. Continued on 9099C... Unsubstantiated A finding of UNSUBSTANTIATED means even though the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Mary Margaret Chappell and a copy of this report was left with Mary.the state’s words, verbatim · CDSS document, Nov 27, 2023 · control 27-AS-20231030140239

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management visit regarding a staff member no longer being employed. LPA explained purpose of visit to the administrator. LPA Lewis spoke with the administrator regarding S1 no longer being employed. LPA was informed that S1 only interviewed and went for fingerprint clearance and the fingerprint clearance did not clear so facility did not move forwarded with employment. Per California Code of Regulations, Title 22 no deficiencies were observed or 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, Nov 27, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required annual inspection visit. LPA met with Administrator and explained purpose of visit. Administrator's Certification expires . LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV areas, and outside yard of the facility to ensure compliance with Title 22 regulations. Food supply is adequate for two day perishable and seven day nonperishable. Fire extinguishers were last inspected May 17, 2023. Smoke alarms were tested and are operational. The facility has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109.7 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present is background cleared. LPA reviewed four staff and five resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility. There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22. LPA received the following updated documents: LIC 308 Designation of Administrative Responsibility, and copy of current Administrator’s Certificate. Exit interview conducted with Administrator. A copy of report and LIC 811 (Confidential Names) left at facilitythe state’s words, verbatim · CDSS document, Oct 9, 2023