397003261-3-28-2023-27-AS-APAA-CQCKRQ-20230328080818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 03/27/2023
Date Signed: 03/28/2023 08:08:51 AM

Document Has Been Signed on 03/28/2023 08:08 AM - 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:	KATELYN LEDESMA		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 127	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Katelyn Ledesma		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/27/2023 at 9:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA Pascua was greeted by staff member (SM), Reese Nimo and explained the purpose of the visit. It was at this time where it was asked for SM Nimo to call the Facility Designated Administrator to inform them that CCL was present. LPA Pascua was able to meet with LVN and Wellness Coordinator (WC), Marites A. Rita and Business Office Coordinator (BOC), Christina Gorforth. LPA Pascua was able to speak with Facility Designated Administrator (FDA), Katelyn Ledesma. It was learned at this time that FDA Ledesma was unable to come right away and would be arriving at the facility within the next hour. FDA Ledesma informed LPA that she was able to start the annual visit with both the WC and BOC. At 10:30am, LPA met with FDA Ledesma. A brief interview with FDA Ledesma was conducted. Current Census was 127. This facility is licensed for 180 residents, of which 31 may be non-ambulatory and 12 bedridden. This facility also has a dementia plan on file. There are currently 103 residents who reside in assisted living and 24 residing in memory care. LPA reviewed 20 resident files. All resident files were current and up to date. LPA reviewed 20 staff files. All staff files were current and up to date. Administrator has an active and current administrator certificate #6063105740 and expires on 07/14/2024. A tour of the facility was conducted. Medication cabinet was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility has an electronic Medication Administration Record system. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time. First aid kit was observed to be present and contained all of the required components at this time. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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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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
	VISIT DATE: 03/27/2023

NARRATIVE

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Office rooms and other areas intended for resident use were toured.
Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible to the residents at this time. It was observed in that the facility has cafe areas equipped with a microwave and addition refrigerator present to cool, heat, and warm up food of the residents if necessary.
Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of the facility memory care unit was conducted.
Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time.
Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 12/09/2022 by the local fire extinguisher company noted as Fire Master Inc. and in compliance at this time. All smoke and carbon monoxide detectors were present and working at this time.

The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308
-LIC 400
-LIC 500
-LIC 610
As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Facility Designated Administrator, Katelyn Ledesma.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

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