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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 12/01/2021
Date Signed: 12/01/2021 01:21:45 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: 114DATE:
12/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH: Executive Director (ED) Sara MackedskyTIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookedale Tracy to conduct a Case Management Visit regarding a reported AWOL incident that occurred on 11/7/21. LPA was greeted by Marites Rita, Nurse (S1), and met with Executive Director (ED) Sara Mackedsky via telephone. ED was out sick but dialed in to discuss the visit.

Incident Report submitted on 11/16/2021 indicated that on 11/7/21 at 12:45am during routine rounds the staff noticed R1 was not in the room. Staff immediate searched for R1 finding R1 in the parking lot laying on the ground on R1s right side. R1 complained of right arm, back, and leg pain, Medtech (S2) contacted 911 and R1 was transported to San Juaqion General Hospital. R1 returned to facility same day. Facility moved R1 to Memory Care Unit. S2 and ED contacted RP of incident on the day of incident.

During record review, LPA observed that R1’s LIC602 stated that R1 may not leave facility unassisted. LPA observed S2 has recieved the following training: Preventing Catastrophic Reactions, Preventing and Responding to Elopment, Managing Elopement, Falls Management, What is Dementia?, Differing Dementias prior to incident.

Based on interviews conducted by LPA and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D.
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2021
Section Cited

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87411(a)-Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.-
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This requirement is not met by: Based on observation and record reviewR-1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.
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Type A
12/02/2021
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...any; and disposition of the case.
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This requirement is not met as evidenced by: Administrator submitted elopement incident 9 days later. Based on Administrator did not submit Incident report timely. This violation poses an immediate health, and safety risk to residents in care.
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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: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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