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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 12/01/2021
Date Signed: 12/03/2021 07:41:18 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:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 114DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH: Executive Director (ED) Sara MackedskyTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookedale Tracy to deliver the finding of the above allegations. LPA was greeted by Marites Rita, Nurse, and met with Executive Director (ED) Sara Mackedsky via telephone. ED was out sick but dialed in to discuss the visit.

LPA inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining/ living room areas. Fire Drill Log conducted 11/29/2021. Ansel system serviced on 6/25/2021, Fire extinguishers serviced on 12/5/2020, Elevatior service on 12/17/2020. Ecolab reports of monthly serviced dated 1/21/2021-11/18/2021. Water Temp in Memory Care measure at 110.8 with S1. Water temperature in Assisted Living measured at 108.8 with S1.

LPA inspected Memory Care and Assisted Living communities. LPA observed PPE supplies available at front lobby. LPA observed extra gloves available in common areas. LPA observed Office Receptionist conducting wellness check and documenting information on sign in sheets. LPA observed activity calendar posted, LPA observed residents participating in a caroling activity in main lobby. LPA observed during lunch meal time, no more than 4 residents to a table. Menus posted. LPA observed food prep in kitchen, Food was covered and dated, Sufficient 7 day non-perishable and 2 day perishable foods available.

LPA reviewed 8 staff files: 4 from Assisted Living 4 from Memory Care
56 total staff vaccinated (4 partial vaccinated/7 exempt/5 on leave of absence). LPA reviewed 8 resident files: 4 from Assisted Living 4 from Memory Care
108 total vaccinated (6 declined).

809 CONT. >>>>>>>>>>>>>>>>>>>>>>>>>>>
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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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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
VISIT DATE: 12/01/2021
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809 CONT. >>>>>>>>>>>>>>>>>>>>>>

LPA inspected the Mediation room. LPA observed medications locked and stored per resident, proper disposal procedures implemented, S1 stated facility has OmniCare conducts audits quarterly. Last Omnicare Audit report 10/30/21

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with S1 and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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