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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 02:09:39 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Priya Lal TIME COMPLETED:
02:00 PM
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On 12/04/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management 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 two incident reports received by the department on 11/02/2023 and 11/22/2023.

The Unusual Incident Report (UIR) received by the department on 11/02/2023 states that a resident noticed that they initially had $138 in her wallet shortly after found that they only had $43 left. The facility conducted an internal investigation. LPA reviewed a copy of the internal investigation and it was found that an interview with the POA was conducted and it was reported that the wallet was not checked since 10/19/2023 and could not recall any suspicious persons and incidents that happened. The facility conducted a room check and conducted staff interviews, however, could not find answers to the missing cash.

An Unusual Incident Report (UIR) received by the department on 11/22/2023 states that a resident felt that their oxygen levels were low and as a result pressed their call button. The resident could not get anyone to help them therefore had to resort to calling his wife. The resident reported that they did not get support from any staff members until 30 minutes after their call button was pressed. LPA reviewed facility documents. Based on document review, it was learned that there was lack of communication between the two care staff members at the time of the incident. The facility conducted an internal investigation, as a response the facility conducted additional training and provided the staff members with corrective action plans to ensure that this incident should not happen again.

Based on the information gathered during today's visit. No deficiencies are being cited. An exit interview was conducted and a copy of this report was provided to 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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