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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 10/12/2023
Date Signed: 10/12/2023 07:46:04 PM


Document Has Been Signed on 10/12/2023 07:46 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:PRIYA LALFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 121DATE:
10/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alex Chipponeri TIME COMPLETED:
01:30 PM
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On 10/12/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a case management visit. LPA met with, Health and Wellness Director (HWD), Alex Chipponeri and explained the purpose of the visit.

Current census was 121. A brief interview with HWD Chipponeri was conducted.

The purpose of this visit was to follow up on an incident report that was received by the department on 08/16/2023. This incident report states that on 08/15/2023, the facility conducted a medication count on R1's antibiotic medication and found that R1 had three (3) additional capsules compared to what was noted in the Medication Administrator Record.

LPA reviewed R1's prescription order and the Medication Administration Record where it was found the the Medication Administration Record was signed after administration, however, the facility counted the medication and found that it was incorrect. The facility informed the Primary Care Physician where they were able to extend the prescription order to allow R1 to take the rest of the antibiotics. It was learned that the staff member who was responsible for the extra medication on site has been terminated after several incidents in which medication was not accounted for.

Based on observations, record review, and interviews a Technical Violation for 87465(c)(2).

An exit interview was conducted and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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