397003261-7-28-2021-27-AS-SDOB-C5HKET-20210802075051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397003261
Report Date: 07/28/2021
Date Signed: 07/28/2021 04:20:08 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
06/09/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210609133652

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:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Pamela Bradley, Operations Specialist		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents do not feel safe.
Facility food is not being handled is a safe manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Brookdale Tracy to continue the delivery of citations for the above allegations. LPA met with Pamela Bradley, Operations Specialist.

The initial 10 day Visit was conducted on 6/16/2021.

Per the Department Review of the findings, additional citations have been determined. It was alleged that residents do not feel safe and facility food is not being handled is a safe manner.

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210609133652

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: 07/28/2021

NARRATIVE

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

During the course of the investigation LPAs interviewed residents and staff and toured the facility. LPAs observed food prepared for dinner service was not covered properly. Meat for main course, strawberry dessert, and side dishes were prepared and not covered. During a sub sequential visit, kitchen staff told LPAs food left out were for staff to have. Lunch service was completed. LPAs observed a server pack a to go tray and delivered the tray to a resident. Server delivered it at approx..1pm. Lunch service begins at approx 1130am. LPAs observed dinner being served approx 20 minutes late.

Records reviewed show an increase number of altercations in memory care between the residents. Resident interviews they did not feel safe due to altercations. Records show as preventative measures, medical attention needed for residents due to altercation. Based on interviews and records reviewed, residents do not feel safe and facility food is not being handled is a safe manner have been deemed SUBSTANTIATED.

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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210609133652

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: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(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, …….	1 2 3 4 5 6 7	Administrator/Licensee will provide a letter detailing staffing plan and statement of understanding of the regulation to CCL by the POC date of 7/29/2021.
	8 9 10 11 12 13 14	This regulations was not met by evidence by residents do not feel safe as there are residents having altercations with one another indicating may not be sufficient staffing.	8 9 10 11 12 13 14
Type B 07/28/2021 Section Cited CCR 87555(b)(9)	1 2 3 4 5 6 7	General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.	1 2 3 4 5 6 7	Licensee will conduct a staff training with kitchen staff to ensure understanding regulation. Licensee will submit training agenda and staff sign off sheet by POC date 8/8/2021
	8 9 10 11 12 13 14	This regulation was not met by evidence by LPAs observed food prepared for dinner service was not covered properly. Meat for main course, strawberry dessert, and side dishes were prepared and not covered.	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: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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