397003261-6-17-2021-27-AS-KHOS-C49L3B-20210623082341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 06/16/2021
Date Signed: 06/17/2021 07:54:14 AM

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
06/07/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210607134547

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: 120	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Pamela Bradley, Interim Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Residents are engaging in multiple physical altercations with other residents.
Facility is understaffed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, LPA Arlene Garcia and LPA Albert Johnson visited the facility today to open a complaint investigation for the allegations listed above. LPA spoke with Pamela Bradley, Operations Specialist and advised the purpose of LPA's visit.

It was alleged that residents are engaging in multiple physical altercations with other residents and that the facility is understaffed.

During the course of the investigation LPAs interviewed residents and staff. LPAs reviewed resident records, staff schedules, and timesheets of actual worked hours.

9099 C 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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20210607134547

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: 06/16/2021

NARRATIVE

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9099-C Cont. >>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Based on a information provided through interviews and records reviewed, the allegation that the facility residents are engaging in multiple physical altercations with other residents is Substantiated. On 5/30/21, R1 and R2 engaged in an altercation. R2 was sent to the ER for medical attention. On 5/16/21, R3 and R4 engaged in an altercation. On 4/26/21, R2 and R1 engaged in an altercation.

Based on a information provided through interviews, staff schedules and and timesheets of actual worked hours., the allegation that the facility is understaffed is Substantiated. Due to the number of altercations between residents being reported, the health and safety of the residents in care is at risk for further injury or hospitalization.

This agency has investigated the allegation notice and has found the allegation to be substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct. A copy of this report along with appeal rights was provided 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: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210607134547

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: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 06/16/2021 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:...(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Licensee will review staffing for memory care and provide CCL with an updated staffing schedule with additional staff to ensure the health and safety of residents in care to prevent further altercations by POC 6/17/21.
	8 9 10 11 12 13 14	This requirement is not met as evidence by the number of altercations between residents being reported, the health and safety of the residents in care is at risk for further injury or hospitalization. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	8 9 10 11 12 13 14		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: 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

LIC9099 (FAS) - (06/04)

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