397003261-7-1-2021-27-AS-KHOS-C4NMHP-20210706093752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 07/01/2021
Date Signed: 07/01/2021 02:54:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210601160411

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	ODETTE COLONDRES		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 123	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Sarah Archuleta-Weaver, Clinical Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff is not providing resident showers.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Arlene Garcia and (LPA) Albert Johnsonmade an unannounced visit to Brookdale Tracy to deliver the finding of the above allegations. LPAs met with Sarah Archuleta-Weaver, Clinical Services Specialist Director.

The initial 10 day Visit was conducted on 6/7/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that the facility staff is not providing resident showers.

9099 CONT. >>>>>>>>>>>>>>>>>

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 27-AS-20210601160411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/01/2021

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

9099 CONT. >>>>>>>>>>>>

LPA interviewed OS, S1, S2, and two residents. LPAs reviewed documents of resident shower schedules, resident Skin Integrity Monitoring Forms, and resident refusal forms. Skin Integrity Monitoring Forms notated when showers were given and any observations when conducting shower. LPAs observed shower schedules for each resident. Documents show the schedule matched when the actual showers were provided. LPAs found no evidence that facility was not providing resident showers.

Therefore, the allegation that the facility staff is not providing resident showers is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be Unsubstantiated.

An exit interview was conducted with Sarah Archuleta-Weaver, Director and a copy of this report 9099-A and Appeal Rights was provided to the Director via email.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2021 and conducted by Evaluator Arlene D Garcia

COMPLAINT CONTROL NUMBER: 27-AS-20210601160411

FACILITY NAME:	BROOKDALE TRACY		FACILITY NUMBER:	397003261
ADMINISTRATOR:	ODETTE COLONDRES		FACILITY TYPE:	740
ADDRESS:	355 W GRANT LINE RD		TELEPHONE:	(209) 835-1000
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	180	CENSUS: 123	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Sarah Archuleta-Weaver, Clinical Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Residents’ meals not served due to lack of staffing/scheduling.
Staff are not responding to residents calling for assistance.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Arlene Garcia and LPA Albert Johnson made an unannounced visit to Brookdale Tracy to deliver the finding of the above allegations. LPAs met with Sarah Archuleta-Weaver, Clinical Director.

The initial 10 day Visit was conducted on 6/7/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that residents’ meals not served due to lack of staffing/scheduling and that staff are not responding to residents calling for assistance.

9099 CONT.>>>>>>>>>>>>>>>>>>>

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20210601160411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/01/2021

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

9099 CONT. >>>>>>>>>>>>>>>>

LPAs observed dining service for approximately 20 residents in Assisted Dining Hall. LPAs observed 2 servers, 1 cook, and 1 assistant dishwasher. During service, three residents stated they had to wait anywhere from 15-25 minutes to be served. Interviews revealed management staffing plan to schedule 4 cooks and 6 servers. Two cooks and 3 servers for Assisted Living and two cooks and 3 servers for Memory Care. LPAs observed two servers from Memory Care were also supporting Assisted Living. LPAs observed second server did not get to Assisted Dining Hall until approximately 10 minutes after dining service opened with 20+ residents waiting.

Records revealed that the facility was aware the Nurse Call System/Pendant call system was not functioning properly. The receiver needed to be replaced with the support of the Divisional Technician and Sylversphere technician. Pendant logs revealed response time was approximately more than 5-16 minutes.

Based on information provided through interviews and records reviewed, the allegations that the residents’ meals not served due to lack of staffing/scheduling and that staff are not responding to residents calling for assistance was deemed SUBSTANTIATED. This agency has investigated the allegation noted and have found the allegation to be substantiated, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview conducted with Sarah Archuleta-Weaver, Director and a copy of this report was provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210601160411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B 07/01/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87468(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Since the complaint, Licensee has serviced the call system on April 14,2021. Licensee has provided document showing service completed.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Records reviewed confirms the Nurse Call System was not functioning prior to the complaint being delivered. This poses a potential health, safety or Personal Rights risk to resident in care.	8 9 10 11 12 13 14
Type B 07/01/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.	1 2 3 4 5 6 7	Licensee will review food service staffing and provide CCL with an updated staffing schedule with additional staff to ensure the personal right of residents in care are not violated by POC 7/11/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Interviews confirmed the residents were waiting for their meals for approx.over 1 hour for service. This poses a potential health, safety or Personal Rights risk to resident in care.	8 9 10 11 12 13 14

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
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

LIC9099 (FAS) - (06/04)

Page: 5 of 5