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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 06/16/2022
Date Signed: 06/21/2022 09:14:29 AM

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
04/19/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220419104338
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:SARA MACKEDSYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 118DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Sara Mackedsy TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Facility Administrator is retaliating against Resident
Administrator violated Resident Council regulations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit on June 16, 2022 at 2:00 p.m. to investigate a complaint on the above allegations. LPA met with Executive Director Sara Mackedsy and explained the purpose of today's visit.

Regarding the allegation Facility Administrator is retaliating against Resident. Based on interviews with facility Administrator Sara Mackedsy there has been no action taken to "get rid of" resident. LPA reviewed faciltiy records showing no 30 day notice has been given or any other documentation to residents documenting retaliation. Therefore, the allegation is deemed UNSUBSTANTIATED. 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.

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: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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 3
Control Number 27-AS-20220419104338
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: 06/16/2022
NARRATIVE
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Continued from 9099..



Regarding the allegation administrator violated Resident Council regulations. Based on interviews conducted by LPA the resident council has presented Resident Council meeting minutes to previous facility Administrator’s but not to the current Administrator Sara Mackedsy. It was reported through interviews that the board resolutions were submitted to a previous ED that has not worked at the facility for an extended period of time. The current Administrator advised not having any knowledge of those resolutions. Since the current ED has began working at this facility council representatives confirm they have not presented any new resolutions. Due to inconsistencies it is unclear if previous resolutions have been addressed. Therefore, the allegation is deemed UNSUBSTANTIATED. 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.


No deficiencies are being cited during this visit Per Title 22 Regulations.

Exit interview conducted with Executive Director Sara Mackedsy, and copy of report along with appeals rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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
04/19/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220419104338

FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:SARA MACKEDSYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 118DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Sara Mackedsy TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator violated HIPPA laws
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit on June 16, 2022 at 2:00 p.m. to investigate a complaint on the above allegations. LPA met with Executive Director Sara Mackedsy and explained the purpose of today's visit.


Regarding the allegation administrator violated HIPPA laws. Based on records reviewed facility residents sign documents (LIC 605 Release of Client/ Resident Medical Information) upon admission authorizing facility representatives to have access to their medical information. The facility must have this access to properly coordinate care for residents. Therefore, this allegation is UNFOUNDED.

No deficinices were cited during this visit Per Title 22 Regulations.

Exit interview conducted with Administrator Sara Mackedsy and a copy of this report left at the facility.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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 3