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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 01/10/2022
Date Signed: 01/24/2022 12:30:31 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
12/28/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211228080525
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: 113DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director, Sarah MackedsyTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not have sufficient staff to serve breakfast in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 01/10/2022 at 01:30 p.m. to investigate the above allegations. LPA met with Executive Director Sara Mackedsy and explained the purpose of today’s visit.

Regarding the allegations that facility did not have sufficient staff to serve breakfast in a timely manner. Based on records reviewed and resident interviews the facility does have sufficient staff to serve breakfast timely. LPA reviewed the facility server schedule for two weeks from 12/12/2021 to 12/25/2021. The staff schedule reviewed did not show any missed server shifts during these weeks. The schedule does have two servers for breakfast daily. LPA spoke with four facility residents and none shared any concerns about the meals being served late or not being served at all. Therefore, the allegation is deemed UNSUBSTANTIATED.

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
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 2
Control Number 27-AS-20211228080525
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: 01/10/2022
NARRATIVE
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Continued from page 9099...

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Per title 22 no deficiencies being cited during this visit. An exit interview was conducted with Sara Mackedsy and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2