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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 08/14/2023
Date Signed: 08/14/2023 02:03:29 PM


Document Has Been Signed on 08/14/2023 02:03 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 TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:KATELYN LEDESMAFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 120DATE:
08/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Priya Lal TIME COMPLETED:
11:00 AM
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On 08/14/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit. LPA Pascua was greeted by Facility Designated Administrator (FDA) Priya Lal and explained the purpose of the visit. The purpose of the visit was to follow up on an incident report that was received by the department.

On 06/27/2023, the department received a Special Incident Report (SIR) from this facility that stated R1's physican called the facility stating that R1 called their office and expressed that they wanted to harm themselves. The Health and Wellness Director and Health and Wellness Coordinator called 911 and both went to the resident's room to check on the resident. Upon arriving to the room the Health and Wellness Director observed a serrated knife and scissors within the resident's reach. R1 expressed to the Health and Wellness Director that they had the desire to hurt themselves and had spoken to two other friends who advised that they called the doctor. The Health and Wellness Director stayed on the resident's side until the emergency services showed up.

LPA conducted interviews and reviewed facility files, including but not limited to, R1's physician report, care plan, behavioral records, and change of condition notes.

Based on interview, records review a Technical Violation is being issued today for Section 87705(f)(1).

Exit interview was conducted, due to technical issues a copy of the LIC809 were emailed the facility at the end of this visit. A electronic email response serves as receipt.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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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