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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:28:07 PM

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:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 117DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Sara Mackedsy, Executive DirectorTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Arlene Garcia arrived at the facility to conduct an unannounced case management visit to follow up on an incident that occurred on 08/10//2021 with R1 and R2. LPA Garcia met with Sara Mackedsy, Executive Director.

ED stated since the incident ED has met with Responsible Party (RP) for R1. ED recently had R1 re-evaluated with physician to update Personal Service Plan (PSP) after first altercation that happened in May 2021. PSP dated 6/24/2021. ED confirmed R1 had met with the physician virtually on 8/11/2021. S3 and R1, Responsible Party (RP) accompanied the call. No updates needed on last PSP. ED has conducted own evaluation on Memory Care to ensure residents are being kept occupied and engaged in activities. ED concluded that training in Memory Care was needed and had conducted training with staff.

LPA reviewed R1 and R2 files. LPA conducted a case management inspection to ensure proactive measures were put in place to prevent further incidents. LPA observed current activity calendar posted, materials for activity out on tables ready for resident's use. LPA observed activity area updated with materials readily available to the residents. LPA observed Clarebridge to be organized, neat, and clean.

Based on the interviews, inspection conducted and additional documentation received, the department has closed this case management and no further investigation is required.
Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's case management inspection.
An exit interview was conducted and a copy of this report will be emailed to Sara Mackedsy, Executive Director
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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