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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397003261
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:00:41 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: 123DATE:
07/01/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sarah Archuleta Weaver TIME COMPLETED:
03:15 PM
NARRATIVE
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LPA Albert Johnson made an unannounced POC (plan of correction) visit visit to the facility to verify correction of citations issued during the case management visit conducted on 6/16/2021.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency (87203 Fire Safety) cited on 6/16/2021 has been cleared. Civil penalty is still pending.

Deficiency 87309(a) cited on 6/16/2021 was addressed in an in-service dated on 6/22/2021, however, during the inspection follow-up on 7/1/2021 to this citation, LPAs observed an unlocked cleaning cart in the main hallway unattended on the second floor (Photo taken). When staff attempted to lock the cart it, would not lock.

Also observed were dirty carpets in the stairways and windows with cobwebs throughout the facility. These items were presented to the facility by the resident council on 4/27/2021

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


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
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 cart in the main hallway on the second floor 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 07/02/2021. This is a repeat violation civil penalties assessed.
Type B
07/09/2021
Section Cited

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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.This requirement is not met as evidenced by:
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Based on observation, the licensee did not maintain the facility grounds. LPAs observed dirty carpets in the stairway and cobwebs on the windows (photos taken). This poses a potential safety risk to residents in care.
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POC date of 7/9/2021.
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: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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