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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 11/09/2023
Date Signed: 11/14/2023 03:08:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230911130514
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:KATELYN LEDESMAFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 102DATE:
11/09/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priya Lal TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not follow emergency plan when power went out
INVESTIGATION FINDINGS:
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On 11/07/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator, Priya Lal and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 102. A brief interview with FDA Lal was conducted.

It was alleged that the facility did not follow emergency plan when power went out. During the course of this investigation, LPA reviewed facility documents and conducted interviews. Based on staff interviews it was learned that the facility had a power outage on 09/03/2023 which lasted for 1 hour and 45 minutes and on 09/04/2023 for 2 hours and would turn on and off throughout the day. These power outages were due to the local electrical company shutting off power to the whole block near the facility. It was learned during the interviews conducted that the facility did not have working elevators or emergency lighting and had to resort to using their cellphone lights as “flashlights” to get through the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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 6
Control Number 27-AS-20230911130514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
VISIT DATE: 11/09/2023
NARRATIVE
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In addition, facility staff confirmed that the facility did not have a generator on site at this time and did not have a plan to obtain one. However, based on further interviews with facility staff it was learned that the facility had portable generators on site after the power outages. Based on resident interviews, it was confirmed that the facility did not have any emergency lighting and described the facility as pitch dark. It was also stated that the resident’s did not have emergency flashlights or any items to help them around the facility which was confirmed by facility staff. A review of the facilities 2023 Emergency Manual that was updated in September 2023, it states that the facility must review all emergency manual documents and ensure that all steps must be completed by June 1st annually. On page 64 the Loss of Electricity Policy states that staff must be provided with battery operated flashlights and extra, fresh batteries and to determine if any residents are utilizing any medical equipment that is electrically powered and ensure that back-up power is provided. The policy continues to state that if emergency generator or battery back-up is not available, provisions must be made for some. A review of the Emergency and Disaster Plan for this facility was conducted. It states that the provisions for emergency power would be that the facility will bring a generator as soon as possible in an event of an emergency and emergency flashlights are in place to assist the residents or personnel during this period. During the time of the facility power outages on 09/03/2023 and 09/04/2023 a generator was not brought to the facility during these times and did not provide emergency lighting based on the facility emergency plan. Additionally, the facility staff were not aware that the facility had 2 portable generators on site. Based on the information gathered during the course of this investigation, the facility did not follow emergency plan when power went out.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230911130514

FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:KATELYN LEDESMAFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 102DATE:
11/09/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priya Lal TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility did not ensure residents oxygen was operable
INVESTIGATION FINDINGS:
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On 11/09/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator, Priya Lal and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 102. A brief interview with FDA Lal was conducted.

It was alleged that the facility did not ensure residents oxygen was operable. During the course of this investigation, LPA reviewed facility documents and conducted interviews. During this power outage there were 4 staff members on site who were responsible to oversee both memory care and assisted living. Around 3:30am, the 4 staff members found that the facility was out of power and call the Health and Wellness Director and were directed to check on the residents who had oxygen and ensure that they were operable and had backup batteries or oxygen cylinders were available for each resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20230911130514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
VISIT DATE: 11/09/2023
NARRATIVE
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Facility staff denied that any residents did not have working oxygen tanks and had any issues with their oxygen during the time of the power outage. LPA conducted 5 resident interviews. 5 out 5 residents denied having any issues with their oxygen during the time of the power outage. 5 out 5 residents stated that they had staff help and check on them during the time of the power outages. 5 out 5 resident stated that they all had battery operated concentrators or back up cylinders available for their use. Based on the information gathered, it is unclear whether the facility did not ensure residents oxygen was operable.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230911130514

FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:KATELYN LEDESMAFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 102DATE:
11/09/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priya Lal TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has had multiple power outages.
INVESTIGATION FINDINGS:
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On 11/09/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator, Priya Lal and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 102. A brief interview with FDA Lal was conducted.

It was alleged that the facility had multiple power outages. Based on the information gathered during the course of this investigation it was learned that the facility did have two (2) power outages that were caused by the local electric company on 09/03/2023 and 09/04/2023. These power outages in response to PG&E providing main caused for the whole street the facility was on to be out of power for approximately 2 hours at a time.
The department investigated the above allegations and has determined that the allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility at the end of this visit.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20230911130514
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2023
Section Cited
HSC
1569.695(2)
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(2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is notavailable, the facility shall have a plan and supplies available to provide alternative resources during an outage. This was not met as evidenced by:
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The administrator stated that a statement of acknowledgement shall be conducted. The admininistrator shall provide an updated and comprehensive emergency plan must be sent to the LPA, along with proof of staff training for no less than (1) hour in duration, for the cited section will
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Based on observation, record review, and interviews the facility did not ensure that they followed the emergency plan outlined in their facility manual. It was learned throughout the investigation that the facility had 2 power outages in which the facility did not have emergency lighting, generators available or operable during the power outages. This poses an immediate, health, safety, and personal rigths risk to persons in care.
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be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by the due date of 11/17/2023 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: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6