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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 05/07/2021
Date Signed: 06/09/2021 09:32:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210414163650
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:ODETTE COLONDRESFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 120DATE:
05/07/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Odette ColondresTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff not meeting resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia contact the facility for the purpose of concluding the complaint investigation. LPA spoke to Odette Colondres, Executive Director (ED).

The initial 10 day visit was conducted on 04/12/2021.

During the course of the investigation LPA interviewed ED, Nurse, and RS.

Based on the information provided through interviews and records reviewed, the allegation that staff are not meeting resident's needs is SUBSTANTIATED..

This agency has investigated the allegation notice and has found the allegation to be substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct with via telephone with AD.
A copy of this report along with appeal rights was provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210414163650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2021
Section Cited
CCR
87618(b)(5)
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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611: the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.This regulation was not met as evidence by:
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Facility corrected at time of incident. Admin/Staff Nurse provided in-service training content information and training sign off by employees.
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The licensee did not ensure that staff were knowledgable and trained in the operation of the oxygen tank. Based on interviews, staff were not knowledgable of the operation of oxygen equipment. This poses a potential risk to 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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
LIC9099 (FAS) - (06/04)
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