397003261-2-23-2021-27-AS-KHOS-BYHPR3-20210223103206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 02/23/2021
Date Signed: 02/23/2021 10:02:38 AM

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
12/09/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201209141217

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	KIEHN, ADALINE I		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 111	DATE:	02/23/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Yvette Colondres, Executive Director		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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9

Residents food is not of good quality or sufficient quantity

Residents food is served late due to lack of staffing/scheduling

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs contacted Executive Director Yvette Colondres by phone to discuss and deliver investigative findings on the allegations listed above. The investigation was conducted by LPA Jacobs and consisted of reviews of the facility's records. Interviews with facility management, resident(s) and other witnesses were conducted.

The complaint alleges that resident(s) (R-1,2) food was not of good quality or sufficient quantity and that the food was served late on several occasions due to lack of staffing and/or scheduling related issues. Interviews with the residents and witnesses provided consistent information and evidence that the allegations are valid. The previous Executive Director acknowledged receiving complaints and concerns from residents over the delivery of food to rooms as required by the Local Health Department

Licensing has determined the above allegations are (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201209141217

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: 02/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2021 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply:8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.	1 2 3 4 5 6 7	Plan of Correction: The Facility will submit a written plan of correction within 10 days a complete the corrective action within 30 days of this deficiency. The plan will include a statement of understanding and compliance with this regulation and a development of plans to ensure that food is of acceptable quality when tray service is delivered to the residents' rooms.
	8 9 10 11 12 13 14	This requirement was not met at evidenced by: Statements from residents staff and other witnesses provided consistent information that meal services to residents rooms arrived late, cold and appeared to be unappetizing on several occasions. This poses a potential health and safety issue.	8 9 10 11 12 13 14	delivered to the residents' rooms. Appeal rights provided to the facility.
Type B 03/23/2021 Section Cited CCR 87555(b)(18)	1 2 3 4 5 6 7	87555 General Food Service Requirements( b) The following food service requirements shall apply (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Plan of Correction: The Facility will submit a written plan of correction within 10 days a complete the corrective action within 30 days of this deficiency. the plan will include a statement of understanding and compliance with this regulation and a development of plans to ensure that food is of acceptable quality when tray service is delivered to the residents' rooms.
	8 9 10 11 12 13 14	Statements from residents staff and other witnesses provided consistent information that meal services to residents rooms arrived late, cold and appeared to be unappetizing on several occasions.The facility reported insufficent staffing for food service delivery. This poses a potential health and safety issue.	8 9 10 11 12 13 14	delivered to the residents' rooms. Appeal rights provided to the facility.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021

LIC9099 (FAS) - (06/04)

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