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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 08/07/2025
Date Signed: 08/08/2025 08:41:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250710153326
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:PRIYA LALFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 113DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Priya Lal TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff unlawfully evicted a resident
INVESTIGATION FINDINGS:
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On 08/07/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Priya Lal and explained the purpose of the visit. The purpose of this visit was deliver complaint findings for the allegations above.

Current census was 113. A brief interview with FDA Lal was conducted.

It was alleged that staff unlawfully evicted a resident. Based on interviews conducted, it was learned that a resident was served an eviction notice on 07/07/2025. However, upon review of the facility records compared to the department records it was found that the facility did not provide the eviction notice to the department within 5 days of issuing the notice. In addition, an interview conducted with staff revealed that the notice was in fact not provided to the department. Based on the information gathered, the facility staff unlawfully evicted a resident in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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-20250710153326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
VISIT DATE: 08/07/2025
NARRATIVE
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Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the facility at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250710153326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2025
Section Cited
CCR
87224(f)
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(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.
This is not met as evidenced by:
Based on record review and interview, The license did not ensure they served a lawful eviction to the resident in care.
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Licensee will provide a written plan of correction indicating the steps facility will make in the future to ensure that any future eviction will meet all department requirements by the POC date. In addition, the eviction notice provided to R1 shall be rescinded.
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It was learned that the resident was served an eviction notice on 07/07/2025, however a notice to the department was not provided within 5 days as required. This poses a potential health, safety, and personal rights risks to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3