<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 07/22/2024
Date Signed: 07/24/2024 02:28:16 PM


Document Has Been Signed on 07/24/2024 02:28 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: 108DATE:
07/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Christina Goforth TIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/22/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit LPA met with Facility Designated Representative (FDR), Christina Goforth and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to come to the facility at this time however was available via phone. The purpose of this visit was to follow up on an incident report that was received by the Department on 07/15/2024.

Current Census was 108. A brief interview was conducted with FDR Goforth and FDA Priya Lal via telephone.

Based on the incident report received by the department on 07/15/2024, it was reported by this facility that on 07/15/2024, at approximately 7:55pm, a hospice aide came into the facility to assist R1 with their shower. Upon arrival to R1's bedroom it was found that the resident was not present and a search around the memory care area was conducted. During this search the resident was not found. At 8:00pm the facility initiated the elopement policy by calling Tracy Police Department and notifying them of a missing resident. At approximately, 8:45pm, Tracy Police Department notified the facility that they have located R1 about .3 miles away from the facility and was able to return back to the facility.

Based on interviews conducted it was learned that around on 07/15/2024 at 7:00pm staff was notified that the back gate door was opened indicating that someone was attempting to leave the facility. Staff immediately went to the back door and found one resident. The staff redirected the one resident back to a common area, however did not conduct an interior and exterior search and head count of the residents in memory care. In addition, staff assisting this resident admitted that they did not follow the facilities elopement policy by assuming that there was only one resident attempting to the leave the facility and did not conduct a search of the facility and an initial head count of all residents.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on records review, Brookdale's Senior Living's elopement policy states that the staff should conduct a thorough interior search of the community and should initiate a head count of all residents. This head count is defined as the visual inspection/face-to-face observation and count of the residents. The head count of the residents is required to confirm and validate the presence of every resident. LPA reviewed staff training and revealed that staff has initial training of the facilities Elopement policies during orientation. Moreover, based on the facilities Missing Resident Drills Policy, staff conducts and completes monthly community missing resident drills with the Administrator which was last conducted on 04/24/2024 on PM shift, 05/18/2024 on NOC Shift, and 06/21/2024 on AM shift.
In addition, LPA reviewed R1's physician report dated on 01/21/2021 states that the resident has a dementia diagnosis and cannot leave the facility unassisted. R1's needs and services plan also indicates that they have episodes of wandering and if someone has the door open they will attempt to leave. R1's care plan states that the resident needs redirection and further observation based on their exit seeking behavior.
The facility was reminded that all residents with a dementia diagnosis must have updated physicians reports. This facility was provided a Technical Violation on 07/11/2024 for Section 87705(c)(5).

Based on the above information the facility did not follow the facilities missing resident policy and did not provide observation checks to prevent elopements. As a result, The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Deficiency can be found on the 809D report.

An exit interview was conducted, LIC809, LIC 809-C, LIC 809D and appeals rights were given to the facility at the end of this visit.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/24/2024 02:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2024
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
87464(f)(1) Basic Services Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidence by:Based on interviews and
1
2
3
4
5
6
7
Licensee shall provide a statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
8
9
10
11
12
13
14
record review the facility did not follow the facilities missing persons policy and did not provide observation checks to prevent elopements. R1 was able to leave the facility through the back door from 7:00pm-8:55pm. S1 was notified of someone exiting but did not follow procedure but conducting a thorough check throughout the facility and conducting a head count. This poses an immediate health,safety and personal rights risks to persons in care.
8
9
10
11
12
13
14
by the due date of 07/23/2024 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3