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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:05:43 PM

Document Has Been Signed on 06/13/2023 03:05 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:DANA BURTONFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 180CENSUS: 120DATE:
06/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Katelyn Ledesma TIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/13/2023 at 12:00PM, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator, Katelyn Ledesma and explained the purpose of the visit. The purpose of the visit was to follow up on an facility reported incident that was received by the department on 05/25/2023. A brief interview with FDA Ledesma was conducted. Current census was 120.

The incident reported stated that on 04/27/2023, the Facility Designated Administrator was notified that they witnessed S1 smack a resident on the arm during NOC shift. On 04/28/2023, the FDA was notified by management that they received a phone call that staff witnessed S1 smack a resident during NOC shift between 04/25/2023-04/26/2023 which confirmed the notice that was received the previous day. An investigation was conducted by the facility and S1 was removed from the staffing schedule pending investigation. The investigation conducted by the facility confirmed that S1 smacked R1 while in care. An interview with S2 was conducted and it was learned that they were shadowing S1 during NOC shift. During evening rounds, R1 was exhibiting behaviors and hit S1. S2 witnessed S1 smack R1 back. S1 was terminated from the facility on 05/15/2023.

LPA obtained a copy of S1's personnel file and facility reports. Based on facility records and interview, staff is trained on personal rights of the residents during orientation.

Based on interview and records review there were the following deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview was conducted, a copy of the LIC809, LIC809-D and appeals rights were emailed the facility at the end of this visit. A electronic email response serves as receipt.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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Document Has Been Signed on 06/13/2023 03:05 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/13/2023 at 11:40 AM
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: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
87468.1(a)(1)

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87468.1
Personal Rights of Residents in All Facilities
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This is not met as evidenced by:
Based on interview and record review,
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Facility Administrator stated that a review of the section, 87468.1(a)(1), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at
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The facility did not comply with the section cited above in 87468.1(a)(1).The facility did not ensure that R1 was treated with respect and dignity while in care of S1. S1 was witnessed to smack R1 while in care. This is a immediate health, safety, and personal rights risks to the persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 07/14/2023 COB. Information submitted must include attendees, trainers, and information discussed.

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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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023


LIC809 (FAS) - (06/04)
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