397003261-4-12-2022-27-AS-KHOS-CDGJMH-20220414071023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 03/24/2022
Date Signed: 04/12/2022 01:58:53 PM

Unsubstantiated

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
03/03/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220303162023

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	SARA MACKEDSY		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 116	DATE:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director Mary Margaret Chappell		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is retaliating against resident for filing a complaint
Facility staff are not respecting resident
Facility is charging for services not provided.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on March 24, 2022 at 08:30 a.m. to investigate the above allegations. LPA met with Executive Director Mary Margaret and explained the purpose of today’s visit.

Regarding the allegation facility is retaliating against resident for filing a complaint. Based on records reviewed the facility is not retaliating against resident for filing a complaint. LPA reviewed emails dated August 26, 2021 from the facility nurse to the facility health and wellness director documenting concerns related to Resident 1 needing more care than he is receiving. The emails document the facility staff has contacted the family of Resident 1 regarding the need for more care. The date of August 26, 2021 reflects that facility staff have had concerns for 6 months about Resident 1 possibly needing more care. LPA reviewed a spearate email from
Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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-20220303162023

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: 03/24/2022

NARRATIVE

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Continued from 9099..

October 2021 regarding the need to review the care plan for Resident 1 along with several other listed residents. Resident 1's family does not agree with the Resident 1's need for more care and they feel it is retaliatory in nature. The facility and the complainant have a very different account of what brought on the new assessment of Resident 1. LPA has no way of determining if the facilities actions in reassessing Resident 1 are retaliatory as they both have such different accounts of the situation. Therefore, this complaint is UNSUBSTANTIATED. A finding that a 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.

Regarding the allegation facility staff are not respecting resident based on LPA interviews with 3 facility residents the staff are very kind, and helpful to the residents. LPA spoke with Resident 2 related to the recent zoom meeting in Resident 2's room and also spoke with alleged staff involved. The facility staff and Resident 2 all agreed facility staff left Resident 2's room right away when asked to do so. This is account differs from what the complainant describes so it is not clear what exactly took place during the meeting. Therefore, this complaint is UNSUBSTANTIATED. A finding that a 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.

Regarding the allegation facility is charging for services not provided. Based on records reviewed the facility does have a fee for "reluctance to accept care" written into their pricing schedule for the amount of $539. The fee is related to the time staff takes to convince residents to accept needed care. Resident 1 signed the form on August 02, 2019 acknowledging he received the pricing schedule, and the facility gives out a new pricing schedule to residents or their responsible parties yearly. The facility will give the Resident 1 chances to comply with the assessed care needs as they are aware he is need of more care before taking any further steps. Therefore, this complaint is UNSUBSTANTIATED. A finding that a 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.

No deficiencies were cited per Title 22 an exit interview was conducted and a copy of this report was provided to Executive Director Mary Margaret Chappell.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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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
03/03/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220303162023

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	SARA MACKEDSY		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 116	DATE:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director Mary Margaret Chappell		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on March 24, 2022 at 08:30 a.m. to investigate the above allegations. LPA met with Executive Director Mary Margaret Chappell and explained the purpose of today’s visit.

Regarding the allegation facility is in disrepair based on LPA observation the memory care carpeted hallway does smell very strongly of urine. Therefore, this complaint is 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 deficiencies are being cited per Title 22 Regulations An exit interview was conducted with Executive Director Mary Margaret Chappell and a copy of this report was left at the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20220303162023

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: 03/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/30/2022 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.	1 2 3 4 5 6 7	Administrator will send proof of plan to replace or clean carpets to LPA by 03/30/2022 POC date.
	8 9 10 11 12 13 14	The following requirement has not been met as evidenced by: LPA observed the facility carpets smelling of urine which poses a potential health, safety, risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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