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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 07/19/2021
Date Signed: 07/19/2021 05:13:49 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
06/09/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210609133652
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:ODETTE COLONDRESFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 124DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Pamela Bradley, Operations SpecialistTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff is not sufficient to meet needs of residents.
Residents do not feel safe.
Facility food is not being handled is a safe manner.
Facility is not following menu.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookdale Tracy to deliver the finding of the above allegations. LPA met with Pamela Bradley, Operations Specialist

The initial 10 day Visit was conducted on 6/16/2021.

It was alleged that staff is not sufficient to meet needs of residents, residents do not feel safe, facility food is not being handled is a safe manner, and facility is not following menu.

9099 CONT. >>>>>>>>>>>>>>>>>>>
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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: 1 of 6
Control Number 27-AS-20210609133652
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. >>>>>>>>

During the course of the investigation LPAs interviewed residents and staff. LPAs toured facility. LPA reviewed resident and facility records. It was observed during the facility tour, menus posted in Memory care was 2 days old, menus posted in front lobby was not updated with changes to what was being served. LPAs observed food prepared for dinner service was not covered properly. Meat for main course, strawberry dessert, and side dishes were prepared and not covered. During a subsequential visit at lunchtime, kitchen staff told LPAs food left out were for staff to have. Lunch service was completed. LPAs observed a server pack a to go tray and delivered the tray to a resident. Server delivered it at approx.. 1pm. Lunch service begins at appro 1130am. LPAs observed dinner being served approx 20 minutes late. Residents stated they are having to wait approx 20-30 minutes for their meals. LPAs observed the same staff that provided food service to Memory Care was moved to provide food service to Assisted Living.

Records reviewed show an increase number of altercations in memory care between the residents. Resident interviews they did not feel safe due to altercations. Records show as preventative measures, medical attention needed for residents due to altercation. Based on interviews and records reviewed, the allegations staff is not sufficient to meet needs of residents, residents do not feel safe, facility food is not being handled is a safe manner, facility is not following menu have 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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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)
Page: 2 of 6
Control Number 27-AS-20210609133652
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
80078(a)
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Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by
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Administrator/Licensee will provide a letter detailing staffing plan and statement of understanding of the regulation to CCL by the POC date of 7/20/2021

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Based on interviews and records reviewed, the licensee did not ensure there was enough staff to support residents requiring additional supervision as notated in their Needs and Services. There was not enough staff to serve residents meals in a timely manner. This poses an immediate risk to residents in care.
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Type B
07/19/2021
Section Cited
CCR
87555(b)(6)(28)
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(b) The following food service requirements shall apply:

(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.

(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
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Licensee will conduct a staff training with kitchen staff to ensure understanding regulation. Licensee will submit training agenda and staff sign off sheet by POC date 7/29/2021
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This regulation was not met by evidence of menus not posted, update, or out of date. Food prepared left out uncovered.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 6
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
06/09/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210609133652

FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:ODETTE COLONDRESFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 124DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Pamela Bradley, Operations SpecialistTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff not providing incontinent care.
Facility does not provide supplies for incontinent care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookdale Tracy to deliver the finding of the above allegations. LPAs met with Pamela Bradley, Operations Specialist

The initial 10 day Visit was conducted on 6/16/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that the staff not providing incontinent care and the facility does not provide supplies for incontinent care.

9099 CONT. >>>>>>>>>>>>>>>>>>>>>>
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 6
Control Number 27-AS-20210609133652
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.>>>>>>>>>>>>>>>

LPAs toured facility and observed resident supplies that receive incontinent care to be sufficient. Records reviewed show incontinent order service available to residents. LPAs interviewed 1 of 7 residents. Five residents are not credible historian. 1 resident refused to be interviewed. R1 stated they were pleased with the incontinent care provided. R1 stated staff were patient and respectful. R1 stated he received care in a timely consistent manner.

Therefore, the allegation that the facility staff is not providing resident showers 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.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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)
Page: 5 of 6
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
06/09/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210609133652

FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:ODETTE COLONDRESFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: DATE:
07/19/2021
UNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Pamela Bradley, Operations SpecialistTIME COMPLETED:
03:08 PM
ALLEGATION(S):
1
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Staff forced resident to eat meal on the floor.
Administrator is not managing the facility and staff appropriately.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookdale Tracy to deliver the finding of the above allegations. LPA met with Pamela Bradley, Operations Specialist.

The initial 10 day Visit was conducted on 6/16/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that the staff forced resident to eat meal on the floor and the Administrator is not managing the facility and staff appropriately.

The complaint does not specify the resident, therefore the LPA could not interview. The Administrator and the staff alleged in the complaint no longer work for the facility. LPA reviewed staff files. LPA unable to interview and confirm. Based on this information, the allegations deemed UNFOUNDED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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: 6 of 6