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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:09:52 PM


Document Has Been Signed on 12/04/2023 02:09 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:PRIYA LALFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 115DATE:
12/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priya Lal TIME COMPLETED:
12:00 PM
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On 12/04/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a Plan of Correction (POC) visit. LPA met with Facility Designated Administrator (FDA), Priya Lal and explained the purpose of the visit.

Current Census was 115. A brief interview with FDA Lal was conducted.

The purpose of this visit was to follow up on prior deficiencies and plan of corrections that were due on 11/17/2023 from a complaint visit conducted on 11/09/2023.
LPA reviewed POC to ensure that the POC has been met. As the date of this visit, the POC has been met and cleared.
A copy of the Plan of Correction letter was provided to the facility.

As a result of this visit, no deficiencies are being cited during the course of this visit. An exit interview was conducted and a copy of this repot was left with the facility.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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