397003261-7-19-2021-27-AS-SDOB-C5JTQS-20210803145624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 07/19/2021
Date Signed: 07/19/2021 04:55:47 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-20210609142226

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:	11:46 AM
MET WITH:	Pamela Bradley, Operations Specialist.		TIME COMPLETED:	12:47 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Kitchen equipment is in disrepair.
Staff are not providing appropriate supervision of residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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. (AD)

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

It was alleged that kitchen equipment is in disrepair and that the staff are not providing appropriate supervision of residents.

9099 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)

Page: 1 of 5

Control Number 27-AS-20210609142226

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

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
26
27
28
29
30
31
32

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

During facility tours, LPA found dish sanitizer in Memory Care not functioning, buffet station in Memory Care leaking, no working thermometers in Assisted Living to check food temperatures. LPA reviewed Needs and Service Plans for residents in Memory Care that stated residents exhibiting increase behavioral concerns. Records reviewed show increase number of resident incidents in Memory Care. Based on interviews and records reviewed, the allegations that kitchen equipment is in disrepair and that the staff are not providing appropriate supervision of residents’ 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 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)

Page: 2 of 5

Control Number 27-AS-20210609142226

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)
Request Denied Type A 07/19/2021 Section Cited CCR 87705(4)	1 2 3 4 5 6 7	Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:...(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Licensee will review staffing for memory care and provide CCL with an updated staffing schedule with additional staff to ensure the health and safety of residents in care to prevent further altercations by POC 7/20//21.
	8 9 10 11 12 13 14	This requirement is not met as evidence by the number of altercations between residents being reported. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type B 07/19/2021 Section Cited HSC 80087(a)	1 2 3 4 5 6 7	Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will have the sanitizer and the buffet station fixed. Licensee will provide the kitchen staff with working thermometers. The facility will provide proof of service completion to LPA by POC date 7/29/21.
	8 9 10 11 12 13 14	Based on observation, the licensee did not maintain the facility grounds. LPA observed broken sanitizer, leaking Buffet station, missing thermometers. This poses a potential safety risk to residents in care.	8 9 10 11 12 13 14

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 5

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-20210609142226

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:	11:46 AM
MET WITH:	Pamela Bradley, Operations Specialist.		TIME COMPLETED:	12:47 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handle resident roughly.
Facility is retaliating against persons who report complaints.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.

It was alleged that the staff handle resident roughly and the facility is retaliating against persons who report complaints.

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

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 5

Control Number 27-AS-20210609142226

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

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
26
27
28
29
30
31
32

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

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. The complaint does not specify the resident, therefore the LPA could not interview. The complainant does not specify the persons or the form of retaliation. LPA unable to interview and confirm. LPA reviewed staff files for any disciplinary actions taken on staff that have been reporting concerns to management. Records reviewed did not show consistent write up with staff that had not been properly investigated by management to warrant action.

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 (AD) and a copy of this report 9099-A and Appeal Rights was provided to the Director 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)

Page: 5 of 5