<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 10/12/2023
Date Signed: 10/12/2023 07:45:40 PM


Document Has Been Signed on 10/12/2023 07:45 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:
01:30 PM
MET WITH:Alex ChipponeriTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 the visit was to follow up on an incident report that was received by the department on 09/13/2023. The incident report states that R1 disclosed to facility staff that she was hit by R2 a couple days prior to notifying staff.

Based on interviews conducted, it was learned that R1 notified facility staff that they wanted PRN medication to help with their pain on their arm. R1 explained to facility staff that they believe that their arm hurt due to R2. However, facility staff did not observe any redness or indications that they were hit. R1 was not able to explain that they were hurt by R2 at the time of interview.

Based on the information gathered today there are no deficiencies being cited during this visit. An exit interview was conducted and a copy of this report was provided to this 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)
Page: 1 of 1