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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 02:05:28 PM


Document Has Been Signed on 08/14/2023 02:05 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: DATE:
08/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Priya Lal TIME COMPLETED:
02:30 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) 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.

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

A special incident report (SIR) was received by the department on 05/16/2023 an incident between three residents in memory care. Based on the SIR it states that R1 was attempting to exit the building while R2 and R3 were trying to stop them. According to R3, R1 hit them on the arm and pushed R2 out of the way. R3 did not complain of any pain or discomfort. The facility continued to monitor R3 for any pain or discomfort. The facility separated the resident's immediately and redirected R1 to their room.

LPA Pascua conducted interviews and reviewed facility records for R1, R2, and R3.
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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