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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 06/16/2021
Date Signed: 06/16/2021 05:03:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BROOKDALE TRACYFACILITY NUMBER:
397003261
ADMINISTRATOR:ODETTE COLONDRESFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:180CENSUS: 120DATE:
06/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:01 PM
MET WITH:Pamela Bradley, Operational SpecialistTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Albert Johnson and Arlene Garica arrived unannounced to open a complaint investigation. LPA met with the Pamela Bradley and staff.

The purpose of this case management report is to detail the findings observed during the tour of the facility, LPA observed in the kitchen the fixed or Ansul system outdated, last service was on 9/2/2019. The system is scheduled to be checked semi- annually (Photo taken). LPAs' also observed unlocked cleaning chart in the main hall way unattended (Photo taken).

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Civil penalties assessed.

Exit interview held and a copy of report was emailed along with appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BROOKDALE TRACY
FACILITY NUMBER: 397003261
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations
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adopted by the State Fire Marshal. The "Fixed System" in the kitchen. This system is scheduled for a semi-annual maintenance and LPA observed that the last service was on 9/02/2019
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 new tags as proof and submit Statement of Compliance by POC date**Fire Clearance Civil Penalty Assessed***
Type A
06/17/2021
Section Cited

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Storage Space. Any item which could pose a danger to residents, including cleaning solutions, poisons, and other items, shall be made inaccessible to residents. LPA
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observed unlocked cleaning chart in the main hall way unattended. This poses an immediate health and safety risk to residents in care
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 Licensee shall submit curriculum and date of training to Licensing by 06/17/2021
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021
LIC809 (FAS) - (06/04)
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