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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:18:19 PM

Document Has Been Signed on 11/09/2021 02:18 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:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 180CENSUS: 117DATE:
11/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Sara Mackedsy, Executive DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst, LPA Arlene Garcia visited the facility today to conduct a case management visit. . LPA spoke with Sara Mackedsy, Executive Director and advised the purpose of LPA's visit.

ED informed LPA the facility had bed bugs. On 9/25/21 (S1) observed in Room 215 had bed bugs.. On 9/26/21 (S2) observed in Room 234. ED contacted Ecolab came out on 9/26/21 and confirmed they were bed bugs. Ecoloab conducts regular pest controls service monthly. Terminex conducted an assessment on 9/27/21. Assessment revealed Room 235 had a dead Bed bug. Terminix conducted heat treatment on 10/5/21. Terminix did a full follow up facility "canine" inspection for any potential areas that could not be visually confirmed. Termiinix conducted an additional heat treat to seven rooms on 11/4 and 11/5. ED was not aware an incident report needed to be submitted because facility took actions immediately after facility was aware of infestation.

Based on information provided through interviews and records reviewed, these allegations are deemed SUBSTANTIATED. This agency has investigated the allegations noted and have found the allegations to be substantiated, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with ED, Sara Mackedsy and a copy of this report was provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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 11/09/2021 02:18 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 11/09/2021 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
80087(a)(1)

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80087 Buildings and Grounds



(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Administrator had Terminix heat treat the infected areas on 10/14, 11/4, 11/5. Administrator has provided LPA with copies of invoices at time of visit.
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This requirement is not met as evidenced by:
This regulation was not met by evidence by, Based on interviews and observation, bed bugs were discovered in room multpile rooms. This poses a potential health risk to the residents in care .
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Type B
11/19/2021
Section Cited
CCR80061(b)(1)(E)

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80061(b)(1)(E) Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

(1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Adminsitrator will submit a letter of understanding of the the reporting requriements to LPA via email by POC date.
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This requirement was not met by: Licensee failed to report the infestation of bed bugs to the department. This poses a potential risk to the residents 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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