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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 01/25/2024
Date Signed: 01/29/2024 11:57:46 AM


Document Has Been Signed on 01/29/2024 11:57 AM - 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: 100DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Priya LalTIME COMPLETED:
02:30 PM
NARRATIVE
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On 1/25/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit. LPA met with Facility Designated Administrator (FDA), Priya Lal and explained the purpose of the visit.

The purpose of the visit was to follow up on multiple incident reports that were relieved by the department via fax on, 12/20/2022, 12/22/2024, 1/03/2024, 1/07/2024, 1/09/2024.

Current census was 100. A brief interview with FDA Lal was conducted.

LPA conducted interviews and reviewed records pertaining to the information provided in the incident reports.
Based on the interviews and records reviewed, there are no deficiencies during the course of this visit.

An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit. Due to printer issues, the LPA provided an email copy to the Facility Designated Administrator. A read receipt confirms that the report was received.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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