<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 11/05/2020
Date Signed: 11/19/2020 11:23:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:KIEHN, ADALINE IFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 111DATE:
11/05/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adaline Kiehn, Facility AdministratorTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bruce Jacobs conducted a Case Management phone call to discuss deficiency observed during a complaint investigation and spoke with Executive Director Adaline Kiehn

During a separate complaint investigation, it was observed the facility did not document bruises and discolorations the arms of R-1 (see confidential names list, LIC 811 dated 11/05/20). During the investigation, interviews were conducted with hospice care staff, facility Health and Wellness Director and several direct care staff. Hospice staff stated they first observed bruising and marks on R-1 on 6/26/2020 and that on 6/29/2020 facility executive director was still unaware of of marks or bruises observed on R-1. The facility's Health and Wellness Director confirmed that hospice staff were the first to bring the bruising to her attention. LPA interviewed multiple direct care staff members who stated they did not observe any marks or bruising that required documentation or needed to be reported even though they assist R-1 with getting dressed and additional activities for daily living. LPA also noted that shift reports did not document any unusual skin conditions.

The following deficiency is cited per California Code of Regulations, Title 22 chapter 8, see LIC 809-D.

Exit interview was conducted and appeal rights issued. A copy of this report will be emailed to the facility for signature.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (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.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2020
Section Cited

1
2
3
4
5
6
7
Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning.... When changes of a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person.
8
9
10
11
12
13
14
.This requirement was not met as evidenced by: Resident (R-1) had significant bruising and skin tears on her hands and arms observed by hospice on 06/29/20 but not brought to the attention of the physician or responsible party for about 10 days after the bruising was observed. This poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
A written Plan of Correction to schedule in-service staff training is due by 11/16/20 and completion of in-service staff training due within 30 days.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2