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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 07/11/2024
Date Signed: 07/11/2024 07:44:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/11/2024 07:44 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR/
DIRECTOR:		PRIYA LALFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 180CENSUS: 109DATE:
07/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Priya Lal TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 07/11/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual continuation visit. LPA met with Facility Designated Administrator (FDA), Priya Lal and explained the purpose of the visit.

The purpose of this visit was to continue an annual visit conducted on 04/25/2024 and 05/09/2024.

Current census was 109. A brief interview with FDA Lal was conducted.

During the course of this visit, LPA toured the facility and reviewed facility resident records.
LPA reviewed 8 resident files during this visit. LPA reviewed a total of 14 resident files throughout the annual visit. Based on record review, it was found that 6 out 14 resident files do not have a pre-appraisal assessment on file. Based on interviews conducted with facility staff it was learned that the facility has been directed to use the company's personal service assessment and discontinue the pre-appraisal form. However, this LPA reviewed the Personal service assessment form and found that it does not capture assessment for the following areas: Medication, Service needs, Ambulatory status, TB test conducted, and social factors.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610
A technical violation is being provided for the following sections 87705(c)(5) and 87457(c).
Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights and a copy of this report were provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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 07/11/2024 07:44 PM - It Cannot Be Edited


Created By: Arielle Pascua On 07/11/2024 at 12:05 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/31/2024
Section Cited
CCR
87457(c)

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(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This is not met as evidenced by:
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The licensee shall provide current Personal Assessment to the LPA for review to ensure that it is in comparison with admission criteria specified in Section 87455, along with an updated plan of operation to reflect change. Licensee shall conduct Pre-Appraisal
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Based on record review and interview, 6 out of 14 resident files reviewed did not have a Pre-Admission appraisal conducted that was in comparision with the admission criteria specified in Section 87455. This poses a potential health, safety, and personal rights risks to persons in care.
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documentation for all prospective residents until Personal Service Assessment has been reviewed by the department to ensure complaince with Section 87457(c). A statement of acknowledgement along with a statement of correction shall be provided to the LPA by POC date.

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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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