397003261-11-5-2020-27-AS-KHOS-BV8NCT-20201110092116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 11/05/2020
Date Signed: 11/05/2020 09:40:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200707155535

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	KIEHN, ADALINE I		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 111	DATE:	11/05/2020
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Adeline Kiehn, Executive Director		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident (R-1) sustained unexplained injuries while in care as a result of abuse or neglect.

INVESTIGATION FINDINGS:

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On 11/04/20 Licensing Program Analyst (LPA) Bruce Jacobs conducted an unannounced tele-visit to Brookdale Tracy RCFE to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator Adaline Kiehn and discussed the investigation detail and findings.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated. The Department conducted interviews with the facility Executive Director, direct care staff and "Visiting Angles" staff who monitored alleged victims care and staff interactions with alleged victim. The Department was not able to interview the victim as she passed away. Witnesses interviewed did not observe any behavior that could explain injuries including self harm. Witnessed described the alleged victim as combative at times and was observed by several witnesses flailing arms.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglect/Lack of Care are unsubstantiated. There are no deficiencies noted or cited per California Code Regulation, TITLE 22, DIVISION 6, CHAPTER 8. Exit interview was conducted with the facility administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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