397003261-9-7-2022-27-AS-APAA-CJ2VJ6-20220907162811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 09/07/2022
Date Signed: 09/07/2022 04:28:17 PM

Document Has Been Signed on 09/07/2022 04:28 PM - It Cannot Be Edited

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 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:	DATE:	09/07/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Chinny Takhar		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced case management facility visit on 09/07/2022. LPA Pascua was greeted by receptionist, Reese Nimo and explained the purpose of the visit. LPA Pascua asked receptionist, Nimo to contact the facility representative to let them know that CCL was present at this time. Shortly after, LPA Pascua met with Clinical Care Director, Chinny Takhar.

The purpose of the visit was to follow up with the facility about a change of administrator.

The last administrator has left the facility since 07/29/2022, the department has not received a notice from the facility about an active administrator on site at this facility. Based on interviews with several staff members there is no active administrator on site at this time. LPA Pascua also reviewed LIC 500 and did not observe a designated administrator at this time.

As a result of this visit, deficiencies were cited per California Code of Regulations, Title 22 and Health and Safety Code.

Exit interview was conducted, and a copy of 809, 809D, and appeals rights were given to the facility at the end of visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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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Document Has Been Signed on 09/07/2022 04:28 PM - It Cannot Be Edited

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: 09/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/08/2022 Section Cited	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. The following requirement has not been met as evidenced by:
	8 9 10 11 12 13 14	Based on records review and interview with staff, the facility has not had an active administrator since 07/30/2022 which poses an immediate health, safety, and personal rights risks 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

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: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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