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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 10/28/2024
Date Signed: 11/09/2024 01:38:13 PM

Document Has Been Signed on 11/09/2024 01:38 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/
DIRECTOR:
PRIYA LALFACILITY TYPE:
740
ADDRESS:355 W GRANT LINE RDTELEPHONE:
(209) 835-1000
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 180TOTAL ENROLLED CHILDREN: 0CENSUS: 114DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:14 PM
MET WITH:Christina GoforthTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/28/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Representative (FDR), Christina Goforth and explained the purpose of the visit.
The purpose of this visit was to follow up on two Special Incident Reports (SIRs), that were received by the department on 09/16/2024, and 10/24/2024.

On 09/16/2024, the facility reported that at 12:00am, Medication Technician provided a resident with a higher dose than prescribed of PRN medication to the resident. It was stated that this resident was only to obtain half a tablet of rather than a full tablet. The facility provided this medication technician a corrective action plan and was provided an in-service training of the 7 rights of medication.
On 10/24/2024, the facility reported an elopement that happened on 10/22/2024 at approximately 2:00pm.
It was stated that R1 left the memory care area through the back door near the living room. As staff heard the door chime and reported to the back door, the resident was no longer in the area. Simultaneously, the facility staff at the front desk observed R1 near the front of the facility and was seen walking around. This facility staff went outside to redirect the resident back into the facility. The resident's family and hospice agency was notified of incident. LPA reviewed R1's physician report dated on 10/23/2024 states that the resident has a dementia diagnosis and cannot leave the facility unassisted. R1 has a documented elopement on 07/15/2024, where the resident was found an hour after elopement. R1's needs and services plan most recent personal service plan conducted on 07/30/2024 also indicates that R1 has episodes of wandering and if someone has the door open they will attempt to leave. R1's personal service plan also indicates that this resident needs redirection and a close eye due to wandering and exit seeking. The facility also noted that R1 needs to be continuously engaged to avoid her wandering.
Due to insufficient time to review additional paperwork and conduct other interviews, the department will follow up at a later time if warranted.
An exit interview was conducted. Due to printer issues, a copy of this report was provided to the facility at the end of this visit via email.
Lisa RiosTELEPHONE: (916) 969-9685
Arielle PascuaTELEPHONE: (916) 862-5907
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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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: 10/28/2024
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Based in the information gathered during today's visit, the department
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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