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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 06/16/2022
Date Signed: 06/21/2022 09:08:03 AM

Document Has Been Signed on 06/21/2022 09:08 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 TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:SARA MACKEDSYFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 180CENSUS: 118DATE:
06/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:31 PM
MET WITH:Administrator Sara Mackedsy TIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub conducted an unannounced facility visit on June 16, 2022 at 05:30 p.m. to conduct a Case Management (Deficiencies) visit LPA met with Executive Director Sara Mackedsy and explained the purpose of today's visit.


LPA and LPM attended the facility Resident Council Meeting and observed 20 residents openly discuss their complaints and concerns related to the facilities operations.

Based on previous interviews with Administrator Sara Mackedsy during a previous complaint investigation she stated she did mention to Resident 1 "if he continues to file complaints she won't even have a job at the facility anymore." This statement can be interpreted as deterring residents from filing complaints with state licensing.

The following deficiencies are being cited per Title 22 Regulations.

An exit interview was conducted with Administrator Sara Mackedsy and a copy of this report along with appeals rights provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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 06/21/2022 09:08 AM - It Cannot Be Edited


Created By: Sarah Hurt On 06/16/2022 at 05:39 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: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2022
Section Cited
CCR
87468.2(a)(3)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(3)To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. The following requirement has not been met as evidenced by:
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Administrator will provide proof of regulation understanding to LPA by POC date of 06/30/2022.
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Based on interviews with facility staff it has been determined statements were made that would deter residents from filing complaints which poses a potentiol threat to health, safety, or personal rights of 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:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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