397003261-7-19-2021-27-AS-SDOB-C5KSYN-20210804141748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 07/19/2021
Date Signed: 07/19/2021 04:47:55 PM

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
07/12/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210712083619

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	ODETTE COLONDRES		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 124	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Pamela Bradley, Operations Specialist		TIME COMPLETED:	11:38 AM

ALLEGATION(S):

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Staff are not associated to the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Arlene Garcia made an unannounced visit to the facility to investigate complaint allegations noted above. LPA spoke with Pamela Bradley, Operations Specialist and advised the purpose of LPA's visit.

During the course of the investigation, while to previous Executive Director (ED) was on leave, the Licesnee brought in support form other Brookdale locations. On June 15th, administrator (AD) provided supoort to facility and became Interim ED effectve July 6th. From June 28th thru July 9th, Interim AD was on vacation, facility assigned LVN from Brookdale Lodi to support. LPA completed a Facility File Review, records reviewed show during the time AD was supporting prior to submission of paperwork and LVN supporting from Lodi, were both not associated to facility.

CONT.>>>>>>>>>>

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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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Control Number 27-AS-20210712083619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/19/2021

NARRATIVE

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9099 CONT. >>>>>>>>>>>>>>>>

Based on interviews and records reviewed, the allegations the staff are not associated to the facility has been deemed SUBSTANTIATED.

This agency has investigated the allegation notice and has found the allegation to be substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct. A copy of this report along with appeal rights was provided via email.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210712083619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/19/2021 Section Cited CCR 87355(e)	1 2 3 4 5 6 7	Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.	1 2 3 4 5 6 7	Licensee shall use the Guardian System to have the staff fingerprint cleared and associated to the facility or continue the use of fingerprinted and associated staff as required by Title 22 regulations. By POC date of 7/20/21. Licensee will an updated Personnel Record by POC date via email to LPA.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the Licensee did not ensure the staff was fingerprint cleared and associated to the facility prior to working. This possess an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
07/12/2021 and conducted by Evaluator Arlene D Garcia

COMPLAINT CONTROL NUMBER: 27-AS-20210712083619

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	ODETTE COLONDRES		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS:	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Pamela Bradley, Operations Specialist		TIME COMPLETED:	11:38 AM

ALLEGATION(S):

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Administrator is not designated to the facility.
Acting administrator is not qualified to manage the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, LPA Arlene Garcia visited the facility today to open a complaint investigation for the allegations listed above. LPA spoke with Pamela Bradley, Operations Specialist and advised the purpose of LPA's visit.

During the course of the investigation, while to previous Executive Director (ED) was on leave, the facility had a Designation Of Facility Responsibility (LIC 308) posted designating Office Manager (OM). On June 15th, Licensee brought in Administrator (AD) provided support to facility. Last day for previous ED was June 28th. AD was assigned as new Interim ED effecitve July 6th. AD provided documents with proof of submission designating AD as interim ED with qualifications.

Therefore, the allegation that the Administrator is not designated to the facility and the
Acting administrator is not qualified to manage the facility is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be Unsubstantiated.

An exit interview was conducted with Pamela Bradley and a copy of this report 9099-A and Appeal Rights was provided to the Director via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4