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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 02:04:39 PM


Document Has Been Signed on 08/14/2023 02:04 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:
11:00 AM
MET WITH:Katelyn Ledesma TIME COMPLETED:
01:00 PM
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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) Katelyn Ledesma 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.

Current census was 120. A brief interview with FDA Lal was conducted.

A special incident report (SIR) was received by the department on 05/26/2023 an incident between two residents in memory care. Based on the SIR it states that two staff members were assisting R1 into their wheelchair in front of R2's room. R2 was standing and waiting to go into their room where they became impatient with R1 and pushed R1 into their wheelchair. R1 stated that they were okay and did not feel any pain from the incident.

LPA Pascua reviewed facility records for both R1 and R2.

Based on interviews and facility records gathered today, Based on interview and records review there were no deficiencies that were cited during this case management visit. LPA Pascua will come at a later time if further follow up is needed.

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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