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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 10/16/2023
Date Signed: 10/16/2023 05:10:17 PM


Document Has Been Signed on 10/16/2023 05:10 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:
10/16/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 AM
MET WITH:Priya LalTIME COMPLETED:
03:00 PM
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On 10/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator, Priya Lal and explained the purpose of the visit.
Current Census was 121. An interview with FDA Lal was conducted.

The purpose of this visit was response to a phone call that LPA Pascua received this morning regarding R1.

LPA will obtain documentation regarding R1 via email.

No deficiencies cited during this case management visit, exit interview was conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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