Inspection Reports for Brookdale Kettleman Lane

The visit was an unannounced case management inspection focused on legal and non-compliance issues, conducted as a quarterly visit by the Licensing Program Analyst.

The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting requirements.

The inspection was an unannounced Required 1 Year Annual Inspection Visit conducted to ensure compliance with Title 22 regulations.

The facility was found to be in compliance with regulations including adequate food supply, sanitary resident rooms, current fire safety equipment, staff certifications, and proper documentation. No immediate or direct risks were noted.

The visit was an unannounced case management inspection focused on legal and non-compliance issues, conducted as a quarterly visit by the Licensing Program Analyst.

The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training on care and supervision, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting requirements.

The inspection was conducted as a case management incident inspection regarding incident reports received about a staff member threatening a resident on 2025-03-31.

No deficiencies were observed or cited during the case management inspection. The staff member involved was suspended and terminated, and all reporting was done on time and to the required departments.

The complaint involved a staff member threatening a resident (R1). The staff member (S1) was suspended on 2025-03-31, terminated, and has not returned after 2025-04-04. The incident was investigated internally and all required reporting was completed timely.

The inspection was an unannounced case management incident inspection regarding incident reports received on 2025-02-11 about a witnessed fall on 2025-02-05 that resulted in a left hip fracture for resident R1.

No deficiencies were observed or cited during the case management inspection. All reporting related to the incident was done on time and to the required departments. The matter remains under investigation.

The complaint involved a witnessed fall resulting in a left hip fracture for resident R1. The incident was reported timely, and the facility provided relevant documentation including physician's report, care notes, hospice records, and admission agreement. Resident R1 has not returned to the facility since the incident. The investigation is ongoing.

The visit was an unannounced quarterly case management inspection focused on legal and non-compliance issues.

The Licensing Program Analyst reviewed staff training records and found all trainings up to date and completed. The visit emphasized ensuring completed staff training, proper resident assessments, timely communication with physicians and families, and ongoing medication training and reporting.

The visit was an unannounced quarterly case management inspection focused on legal and non-compliance issues, conducted by the Licensing Program Analyst.

The Licensing Program Analyst reviewed staff training records and found that all required trainings were up to date and completed. The visit included review of care and supervision training, resident assessments, communication protocols, and medication training.

The visit was a follow-up Non-Compliance Conference conducted to follow up with the facility after an initial Non-Compliance Conference held on 11/30/2023.

Since the last meeting, one new complaint was filed and found unsubstantiated, and one Type A deficiency was cited related to maintenance and operation. The facility agreed to several corrective actions including submission of personnel summaries, ensuring annual medical assessments for residents with dementia, and providing training materials.

One new complaint was filed and found unsubstantiated against the facility since the last meeting.

The visit was an unannounced quarterly case management inspection conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training.

The review found that all staff training records were up to date and completed. The visit included discussions on care and supervision, resident assessments, communication with physicians and families, and medication training requirements.

The visit was an unannounced quarterly case management inspection conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training and reporting.

All staff training records were reviewed and found to be up to date and completed. The Licensing Program Analyst provided a copy of the report during the exit interview.

The visit was a case management visit conducted as a result of an incident that took place on May 5, 2024, involving a resident with tarry stool and decreased appetite who was hospitalized and later passed away.

The department reviewed the resident's file including physician reports, hospice notes, and facility care notes. The facility did not initially report the resident's death but later provided confirmation that the required death report was faxed within the required reporting period.

The visit was an unannounced Required 1 Year Annual Inspection to evaluate compliance with Title 22 regulations at the facility.

The inspection found the facility generally compliant with regulations including adequate food supply, sanitary resident rooms, and proper certifications for staff. However, a deficiency was cited for the call signal system in room 5 which did not notify staff, posing an immediate health and safety risk.

Unannounced complaint investigation visit conducted in response to a complaint received on 03/19/2024 regarding personal rights allegations at Brookdale Kettleman Lane facility.

The complaint was found to be unsubstantiated due to lack of preponderance of evidence. The facility was observed to be clean, sanitary, and well-maintained with adequate food supply and proper safety measures in place.

Complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not enough evidence to prove the alleged violation did or did not occur.

The visit was an unannounced quarterly case management visit conducted by Licensing Program Analyst Kesha Lewis to review staff training, resident assessments, communication protocols, and medication training and reporting requirements.

The review of random training records showed that all staff trainings were up to date and completed. Trainings were emailed to the Licensing Program Analyst on the day of the visit. An exit interview was conducted and a copy of the report was given.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-08-24 regarding allegations of improper food storage and provision of expired food to residents.

The allegation that staff did not properly store food was substantiated based on observation of prepared desserts stored uncovered in the refrigerator. The allegation that staff provided expired food was unsubstantiated as no expired food was observed during the inspection.

The complaint investigation was substantiated for improper food storage but unsubstantiated for providing expired food. The substantiated allegation involved uncovered prepared desserts in the refrigerator.

The visit was a Noncompliance Conference (NCC) conducted to discuss the facility's substantiated noncompliance related to care and supervision, medication, dental care, reporting requirements, and document furnishing.

The facility had multiple citations over the past 3 years including 5 A citations in care and supervision, medication, and dental care, and B citations in reporting and document furnishing. Specific issues included inadequate supervision, delayed medical care post-fall, and deficiencies in staff training and communication.

The visit was complaint-related with substantiated noncompliance. Citations included 5 A citations in care and supervision, medication, and dental care; 1 B citation in reporting requirements; and 1 B citation in furnishing documents on request.

The visit was an unannounced case management follow-up to an incident report submitted to the Department regarding multiple falls sustained by a resident (R1). The purpose was to investigate the incident and assess compliance with care and supervision requirements.

The investigation substantiated that the licensee failed to ensure sufficient provision to aid in fall prevention for R1, who sustained multiple falls over seven months resulting in injury. Deficiencies were cited related to basic service requirements and failure to update the resident's needs and services plan after the falls.

The complaint investigation was substantiated based on findings that the licensee failed to provide adequate fall prevention and failed to update care plans after multiple falls of resident R1.

An unannounced Annual 1-Year Required visit was conducted to evaluate the facility's compliance with licensing requirements.

The facility was toured and reviewed for compliance including safety, staffing, training, and resident accommodations. No deficiencies were cited during this inspection.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-03-06 regarding allegations that staff denied a resident phone access and visitors.

The investigation found that the resident was placed under Conservatorship which restricted phone and visitor access at the Conservator's request, not the facility's. Therefore, the complaint was unsubstantiated due to lack of evidence proving a violation by the facility.

The complaint was unsubstantiated. Although the allegations may have happened or be valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.

The Licensing Program Analyst conducted an unannounced case management visit to follow up on various incident reports received at the facility.

Several residents received immediate medical care due to incidents including an unwitnessed fall with vaginal bleeding, nausea and vomiting related to Norovirus, and edema. All affected residents returned to baseline and remained in care at the facility.

The visit was an unannounced case management inspection conducted to investigate incidents reported on 1-9-23 and 1-10-23 involving failure to assist residents with prescribed medications.

The facility failed to assist two residents (R1 and R2) with administering prescribed medications, posing an immediate health and safety risk. The facility was otherwise clean, sanitary, and compliant with safety equipment and staffing levels. A civil penalty of $250 was issued due to repeat violations within 12 months.

The complaint investigation was substantiated based on incidents where residents R1 and R2 did not receive their prescribed medications due to facility staff error.

The visit was a case management incident investigation conducted as a result of an incident on November 8, 2022, involving a resident (R1) being given an extra dose of a PRN medication and issues related to treatment and reporting of a rash later identified as scabies.

The facility failed to have a current PRN letter for R1, administered an extra dose of Seroquel not in accordance with physician orders, and delayed reporting a serious incident involving scabies. Deficiencies were cited related to medication administration and incident reporting.

The visit was triggered by a complaint/incident involving a resident receiving an extra dose of PRN medication and delayed reporting of a serious incident related to scabies. The complaint was substantiated with cited deficiencies.

The visit was a case management visit conducted to investigate medication errors reported in incidents submitted to the Community Care Licensing Division on 07/17/22, 08/15/22, and 08/20/22 involving residents not receiving correct medication dosages.

The investigation found that medication was missed or given incorrectly on multiple occasions, posing a potential health, safety, or personal rights risk to residents. A deficiency was cited under California Code of Regulations, Title 22, for failure to assist residents with self-administered medications properly.

The visit was triggered by complaints regarding medication errors involving three residents. The complaint was substantiated based on incident reports and medication logs reviewed during the visit.

The visit was a case management follow-up on an incident report submitted by the facility regarding an unwitnessed fall of a resident on 07/15/22.

The licensee failed to immediately call 911 after a resident's fall resulting in a small laceration, instead contacting the resident's responsible party who transported the resident to the hospital. This deficiency was cited under California Code of Regulations, Title 22.

An unannounced Annual 1-Year Required visit was conducted to evaluate compliance with licensing regulations and facility standards.

The facility was toured and observed to maintain safe and comfortable conditions, including adequate lighting, temperature, and safety features. However, deficiencies were found related to personnel records, including lack of signed employee rights forms in all staff files, one staff member not associated with the facility, and one staff member lacking a health screening.

The visit was a case management inspection conducted in response to an incident report submitted on 2022-04-05 regarding a medication error at the facility.

The inspection found that a medication error occurred where Resident #1 received two doses of Linezolide due to staff miscommunication and failure to check the medication count sheet. No signs of distress were noted in the resident, but the incident posed an immediate health and safety risk.

The visit was complaint-related based on an incident report of a medication error submitted on 2022-04-05. The medication error was substantiated as Resident #1 received two doses of Linezolide. The resident showed no distress and the physician and family were notified.

The visit was a case management investigation regarding an incident submitted to the Community Care Licensing Division on 2022-01-29 involving a medication error.

A medication error occurred on 2022-01-24 where a resident received methadone twice due to a timing error in administration. The facility failed to comply with medication administration regulations, posing potential health and safety risks. Staff involved were reassigned or no longer employed at the facility.

The visit was complaint-related based on an incident report of a medication error. The medication error was substantiated with documentation and interviews confirming the error and subsequent actions taken.

The visit was an unannounced case management follow-up on an incident report received on 12/29/2021 regarding an altercation between two residents on 12/19/2021.

The facility has a history of aggressive behavior in one resident and has proposed an appropriate plan to prevent further incidents. However, the facility failed to meet the 7-day reporting requirement for special incident reports, submitting the report 10 days after the incident.

The visit was complaint-related, following up on an incident report of resident aggression. The complaint was substantiated as the facility failed to report the incident within the required timeframe.

Case management visit regarding a COVID positive resident to assess compliance with reporting requirements.

The facility failed to notify the Community Care Licensing Division within 24 hours of a resident testing positive for COVID-19, which poses an immediate health and safety risk to residents.

An unannounced complaint investigation was conducted regarding allegations that facility staff were forging residents' medical assessments.

The investigation found insufficient information to determine that facility staff were forging residents' medical assessments. The allegations were determined to be unsubstantiated, and no citations were issued.

The complaint alleged that facility staff were forging residents' medical assessments. Interviews with staff and residents' responsible parties, as well as document reviews, did not provide sufficient evidence to substantiate the allegations. The complaint was determined to be unsubstantiated.

The inspection was an unannounced required 1-year annual inspection conducted to evaluate the facility's compliance with licensing regulations.

The Licensing Program Analyst toured the facility and found all areas in compliance with no deficiencies cited. Safety equipment and emergency plans were up to date and operational.

The visit was a Case Management - Incident Visit conducted via telephone due to COVID-19 precautions. It was triggered by an incident report submitted regarding a medication error where five medications were mistakenly given to the wrong resident.

The investigation substantiated that five medications were erroneously administered to Resident 1, posing an immediate health and safety risk. The facility acknowledged the incident and a deficiency was cited under Title 22 Division 6 of the California Code of Regulations.

The incident regarding five medication errors given to Resident 1 was substantiated based on documentation and interviews. There was a preponderance of evidence proving the incident occurred as reported.

report_11_397005466_inx10_2023-01-17.pdf