I'm torn. The community is bright, well-kept and active with friendly, caring staff, good landscaping and lots of amenities - my loved one made friends and enjoys activities. But it's chronically understaffed: slow or missed dining service, laundry/housekeeping lapses, medication and care errors (missed checks, restroom help, bedsores reported), and management/ billing responsiveness is inconsistent. If you want warm staff and programs it's worth a look; if you need reliable medical/memory care and consistent housekeeping, be cautious.
Spacious private 1‑bedroom apartments with kitchenettes
Natural light, views, and large windows
Well‑decorated foyer and common areas
Nicely landscaped grounds, courtyard and patios
Abundant activities and outings
Exercise classes (yoga, bingo, Happy Hour, trips)
Transportation to appointments and shuttle service
On‑site physician and certified medical team
Beauty salon / barber shop and on‑site services
Game rooms, pool table and miniature golf
Secured backyard and outdoor BBQ areas
Housekeeping and laundry service (reported by many)
Hotel‑like atmosphere and welcoming move‑in experience
Active social programs and resident engagement
Hospice care praised
Clean rooms and well‑kept common areas (many reviews)
Apartment appliances (stove, refrigerator) in units
Accessible layout for varied ambulation
Helpful tour staff and informative executive directors
Good value or affordability reported by some reviewers
Cons
Understaffing and slow or delayed response to calls
Inconsistent care quality; reports of neglect
Medication errors and missed checks
Incontinence odor and urine reported in some areas
Bathroom and overall cleanliness problems in some reports
Laundry mixups, missing clothes and poor laundering service
Reports of bed sores, skin tears and rough handling
Concerns about memory care training and management
Management problems, poor communication and turnover
Billing issues, unexpected fees, and rate increases
Lack of transparency about total cost and minimum stay
Older building condition: dated fixtures, carpets, appliances
Inconsistent food quality; some describe poor dinners
Transportation unreliability for appointments
Safety concerns due to nearby homeless tents/crime
Limited private room availability / shared rooms in places
Slow dining room service and long waits reported
COVID lockdown visitation and restricted access complaints
Narrow hallways and limited elevator capacity for scooters
Delayed emergency response and Life Alert failures
Housekeeping inconsistently performed in some units
Staff professionalism varying; some reports of rude/unprofessional staff
Incidents of theft, break‑ins, or criminal activity nearby
Summary review
Overall sentiment in these reviews is mixed but leans toward positive for independent living residents who value an active social environment, friendly staff and good amenities. Most reviewers highlight a warm, welcoming community feel: staff are frequently described as friendly, caring and personable, many residents report becoming socially engaged and happier after moving in, and maintenance and front‑desk responsiveness are noted repeatedly. The physical aspects of Brookdale Tracy that receive consistent praise include spacious one‑bedroom apartments with kitchenettes and natural light, well‑decorated common areas, nicely landscaped outdoor spaces and a broad range of on‑site amenities (beauty salon, game rooms, miniature golf, pool table, courtyard seating and secured outdoor areas). Many families and residents appreciate the active calendar—exercise classes, bus trips, bingo, movie nights and regular outings—which reviewers credit with improving quality of life for independent residents.
Care quality and staffing are the most polarizing themes. Numerous reviewers commend attentive caregivers, an on‑site physician, a certified medical team and well‑run hospice services, with several specific accounts of compassionate, knowledgeable nursing support. However, an overlapping and serious set of concerns appears in multiple reviews: reports of understaffing, delayed responses to call buttons, medication mistakes, missed bed checks and even allegations of neglect (including bed sores, skin tears, rough handling and exposure to soiled diapers). Memory care is repeatedly singled out as an area with mixed or negative feedback—some reviewers found it appropriate and calming, while others reported poor dementia training, lack of supervision, and even incidents that prompted them to remove relatives. These contradictory reports indicate variability in staff training, supervision and staffing levels across shifts and units.
Dining and activities receive mostly positive commentary but with notable inconsistency. Many residents praise the restaurant‑style dining, generous portions, fresh home‑cooked meals and the ability to accommodate special diets (diabetic options noted). At the same time a sizable number of reviews describe uninspired or poor food on some days (especially dinner), long waits in the dining room, slow service and a perception that menus sometimes prioritize cost over resident enjoyment. Activities are widely touted as a strength—there is a rich mix of programs, outings and social opportunities that help residents stay engaged—but a few reviewers felt programming was limited or that community‑led activities had been reduced.
Facility condition and cleanliness are also mixed. Positive comments emphasize clean rooms, well‑kept grounds and hotel‑like public spaces. Countering this are multiple reports of an older building with dated cabinetry, carpets and appliances, narrow hallways and limited elevator capacity that can be inconvenient for scooter users. Several reviewers mention specific cleanliness issues—urine odors in bathrooms and lobby furniture, sticky floors, roach sightings in at least one report and spotty housekeeping—suggesting uneven maintenance or lapses in certain areas. Location is convenient for many (close to Stockton, Livermore and a nearby police station), but some raise safety concerns because of visible homeless tents and local crime incidents.
Management, transparency and billing emerge as recurring pain points. Numerous families reported unexpected charges, opaque total cost estimates, contract timing issues, fee increases and annual rent hikes. Some reviewers describe poor communication from management, turnover at the executive director level, and slow or unhelpful responses when problems arise. These administrative and financial issues, combined with the variability in care quality, are the most frequent reasons families expressed dissatisfaction or ultimately moved relatives elsewhere.
Notable operational risks highlighted in the reviews include emergency response failures (a failed Life Alert and delayed transport after falls are mentioned) and unreliable transportation for medical appointments. Conversely, several reviews state the community provided excellent hospice care and described attentive follow‑up in end‑of‑life scenarios. Laundry service and tracking problems are commonly reported—missing clothes, mixups and inconsistent laundry quality—so families should verify policies and tracking systems.
Recommendation and guidance for prospective families: Brookdale Tracy appears to be a good fit for relatively independent seniors who prioritize social activities, a friendly community, apartment‑style living and on‑site amenities. Prospective residents and families who require consistent, high‑acuity nursing care or secure, well‑staffed memory care should exercise caution, thoroughly investigate staffing ratios and memory care training, and request recent incident logs or quality reports. During a tour, prospective families should observe mealtime service, check multiple apartment units for cleanliness and odors, ask for detailed, written cost breakdowns including any minimum‑stay requirements, inquire about recent turnover in leadership, verify emergency response processes and LifeAlert testing, and discuss laundry and housekeeping schedules. Asking for references from current families and requesting to speak with staff on duty during different shifts can help assess consistency. In short, Brookdale Tracy has many strengths—community, activities, dining and grounds—but also documented weaknesses around staffing consistency, management communication and certain care and cleanliness issues that warrant careful due diligence.
Location
About Brookdale Tracy
Brookdale Tracy sits in a peaceful spot and is a Continuing Care Retirement Community that offers a good range of care, so you'll find assisted living, skilled nursing, memory care, and even adult day care here, all under one roof, which makes it easier for people to stay as their needs change over time, and really, it's one of those places where you can see they've planned out the details for safety and comfort, because you've got 24-hour awake staff, nurses on-site for up to 16 hours daily, and a call system for emergencies that works all the time. Folks living here can get help with bathing, dressing, medication, and other daily needs, with tailored support that matches each person's preferences-plus, for people who need extra help, like diabetic care, incontinence care, or even full nursing with lifts or standby assistance, the staff handles all that, and they do try to make transitions smooth by coordinating with doctors and outside healthcare providers, so folks don't have to worry about gaps in their care.
The memory care setup is in a separate secure building, with technology like bracelets to help prevent wandering-this setup was built with dementia and Alzheimer's care in mind, including special kitchen spaces, routine cognitive programs, and a courtyard with a fountain and pergola for outdoor relaxation. The community is pet-friendly, so residents can keep a dog or cat, and they'll even help with pet care if that's needed, and there are plenty of indoor and outdoor activity spaces, walking paths, a fitness center with low-impact machines like NuStep cross trainers, and a beauty salon with all the basics. Apartments come in different styles, including studios and one- or two-bedroom layouts, with private bathrooms and kitchenettes, and each unit has an emergency call system-wheelchair accessibility is standard everywhere, including the showers and common rooms.
There's a full calendar of resident-run programs, music nights, group movies, gardening clubs, trivia, educational talks, exercise classes like yoga or chair yoga, cooking classes, and things like wine tasting or field trips around Tracy, plus both onsite and offsite devotional or religious services for folks who want them, and you can find a comfortable library, game room, fireside living area, and a dining room with big windows and earth-toned décor. Meals are served restaurant-style, with menus built to be healthy and tasty, and the kitchen uses simple, nutritious ingredients so residents get what they need for wellness.
Brookdale Tracy is licensed to support up to 180 people, and it does have services for residents with more complicated behavioral problems or for those who might be at risk for elopement or physical outbursts-they have secure entry and exit points, and the memory care area is designed to cut down on confusion and wandering. The community offers its own transportation, so people can get to appointments, shopping, or nearby restaurants and events, and there's parking for those who drive, plus it's located near bus lines for easy access.
All in all, you'll see that the whole property is set up to let seniors age in place, from independent living through to advanced care, with spaces for everyday comfort and plenty of programs for mental and social engagement, and with staff on hand at every hour so there's always a helping hand nearby if something comes up.
Brookdale Senior Living Inc. (NYSE: BKD) is the largest senior living operator in the United States, managing over 640 communities with capacity for approximately 59,000 residents across 41 states and employing around 36,000 associates. Founded in 1978 and publicly traded since 2005, Brookdale solidified its market leadership through major acquisitions including American Retirement Corporation (2006) and Emeritus Senior Living (2014), making it the only national full-spectrum senior living company. Headquartered in Nashville, Tennessee, Brookdale has topped the American Seniors Housing Association's ASHA 50 list and Argentum's largest providers list for multiple consecutive years.
The company's comprehensive care continuum includes independent living, assisted living, memory care, skilled nursing, and continuing care retirement communities (CCRCs). Brookdale's signature Clare Bridge program, developed over 30 years ago by dementia-care experts, provides specialized Alzheimer's and dementia care through two distinct levels: Clare Bridge communities for comprehensive memory support and the Clare Bridge Solace program for advanced-stage dementia residents. The program is recognized by the Alzheimer's Association® for incorporating evidence-based Dementia Care Practice Recommendations and features secure environments, enclosed courtyards, Daily Path programming with six structured activities daily, and the InTouch technology platform offering personalized brain-stimulating games and therapeutic content.
Brookdale's holistic Optimum Life® wellness approach balances six dimensions—Purposeful, Physical, Emotional, Social, Spiritual, and Intellectual—implemented through signature programs including B-Fit (eight exercise class options), Brain Fit (mental fitness workouts), My Life Story (resident storytelling), EngagementPlus (interest-based connections), Growing Together (collaborative learning), and The Ageless Spirit (kindness and gratitude practices). The Embrace Family Partnership provides caregiver education and support for families of memory care residents.
The company's Brookdale HealthPlus® care coordination model, winner of the 2024 Argentum Best of the Best Award placing it among the top 1% of operators, is a technology-enabled healthcare service featuring dedicated RN Care Managers who proactively manage residents' health, coordinate care transitions, and help prevent avoidable hospitalizations. Communities using HealthPlus report 78% fewer urgent care visits, 36% fewer hospitalizations, and 63% more completed annual wellness visits. The Personal Solutions program delivers hygiene products, medications, and daily necessities directly to residents' doors with discreet packaging and monthly billing convenience.
Following a strategic divestiture of its home health and hospice operations to HCA Healthcare (completed December 2023), Brookdale now focuses exclusively on senior living operations while maintaining its position as the industry's largest operator, committed to its mission of enriching lives with compassion, respect, excellence, and integrity.
People often ask...
Brookdale Tracy offers competitive pricing, with rates starting at a cost of $3,450 per month.
Brookdale Tracy offers independent living, assisted living, and memory care.
There are 11 photos of Brookdale Tracy on Mirador.
Yes, Brookdale Tracy allows residents to age in place and adjust their level of care as needed.
The full address for this community is 355 W Grant Line Rd, Tracy, CA, 95376.
Yes, Brookdale Tracy offers respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
State of California Inspection Reports
90
Inspections
16
Type A Citations
18
Type B Citations
6
Years of reports
07 Aug 2025
07 Aug 2025
Determined that a resident was unlawfully evicted, because the eviction notice issued on 07/07/2025 was not provided to the department within five days.
§ 87224(f)
14 Jul 2025
14 Jul 2025
Found no deficiencies after an unannounced annual continuation visit; all safety measures, food storage, and resident spaces were in good order.
§ 9058
29 Apr 2025
29 Apr 2025
Found no deficiencies after an unannounced annual visit, with a census of 112 and three resident files and three staff files reviewed and found complete and up to date.
28 Oct 2024
28 Oct 2024
Identified two incidents: a staff member administered a higher dose of PRN medication to a resident than prescribed, and a resident with dementia wandered off the premises, with prior elopement history and care plans noting wandering and the need for close supervision.
22 Jul 2024
22 Jul 2024
Found that a resident with dementia attempted to leave after a back gate opened; staff did not follow the missing resident policy, conduct an interior search, or perform a headcount. The resident was missing until police located them about 0.3 miles away.
22 Jul 2024
22 Jul 2024
Confirmed failure to follow missing resident policy and provide observation checks to prevent elopements.
§ 9058
11 Jul 2024
11 Jul 2024
Identified that 6 of 14 resident files lacked a pre-appraisal assessment after reviewing 8 files during this visit and 14 across the annual review. Noted that the personal service assessment did not capture key areas such as medication, service needs, ambulatory status, TB testing, and social factors; updates to LIC 308, 400, 500, and 610 were requested, a technical violation cited for related regulations, and appeal rights provided.
11 Jul 2024
11 Jul 2024
Identified deficiencies were found during the visit, including missing assessment forms in resident files.
09 May 2024
09 May 2024
Found no deficiencies during an unannounced annual continuation visit, with five resident files reviewed and a site tour conducted; census was 102.
09 May 2024
09 May 2024
Reviewed resident files and conducted facility tour; no deficiencies identified during annual visit.
25 Apr 2024
25 Apr 2024
Identified overall safety and care measures in good condition, with secure medications, locked chemicals, working fire safety equipment, and adequate furnishings; however, a technical violation was issued for one regulation, and a follow-up visit to review records was planned.
25 Apr 2024
25 Apr 2024
Confirmed no deficiencies during the annual visit, with all safety measures and equipment found to be in good working condition.
§ 87464(f)(1)
25 Jan 2024
25 Jan 2024
Investigated follow-up on incident reports, conducted interviews, and reviewed records; found no deficiencies. Exit interview conducted.
25 Jan 2024
25 Jan 2024
Confirmed no deficiencies found during visit to follow up on incident reports.
04 Dec 2023
04 Dec 2023
Found that issues from a prior complaint were addressed and no deficiencies were cited at follow-up.
04 Dec 2023
04 Dec 2023
Investigated two incidents—missing cash from a resident's wallet and a delayed staff response to a resident's call button due to communication gaps—and no deficiencies were cited.
04 Dec 2023
04 Dec 2023
No deficiencies were cited during the visit and the plan of correction was met.
09 Nov 2023
09 Nov 2023
Found that the claim of not following emergency plans during power outages could not be proven and the oxygen operability concerns could not be established. Noted two power outages occurred and no deficiencies were observed.
§ 1569.695(2)
09 Nov 2023
09 Nov 2023
Found that the facility did not follow emergency plan during power outages, but allegations regarding residents' oxygen operability were inconclusive. No deficiencies were observed.
16 Oct 2023
16 Oct 2023
Investigated the allegation R1 after a morning phone call; no deficiencies were cited during the case management visit and an exit interview was conducted.
16 Oct 2023
16 Oct 2023
No deficiencies were cited during the case management visit.
12 Oct 2023
12 Oct 2023
Identified that three extra capsules of an antibiotic were found during a medication count on 08/15/2023, not matching the medication record, and the staff member responsible was terminated after several issues with medication accountability.
12 Oct 2023
12 Oct 2023
Identified an allegation that a resident was hit by another resident. No injuries were observed, and the resident could not confirm being hurt; no deficiencies were cited.
12 Oct 2023
12 Oct 2023
Investigated an allegation that the power of attorney was financially abusing the resident; found no concerns about the POA's actions, no deficiencies identified, and an exit interview was conducted.
12 Oct 2023
12 Oct 2023
Confirmed interview findings did not substantiate the allegation of physical abuse reported at the facility.
14 Aug 2023
14 Aug 2023
Investigated an incident involving three memory-care residents; found no deficiencies cited after reviewing interviews and records, with no pain reported and residents separated and redirected.
14 Aug 2023
14 Aug 2023
Identified an incident on 05/26/2023 in memory care where one resident pushed another while being helped into a wheelchair. Reviewed records and interviews; no deficiencies were cited at that time.
14 Aug 2023
14 Aug 2023
Identified that a resident expressed the desire to harm themselves and had access to a serrated knife and scissors within reach; reviewed medical and care records, leading to a technical violation being issued.
14 Aug 2023
14 Aug 2023
Reviewed incident report of altercation between residents, no deficiencies cited during visit.
13 Jun 2023
13 Jun 2023
Identified two late-April incidents in which a staff member smacked a resident during night shifts. Terminated the staff member in May following the investigation, and training on residents' personal rights was noted.
13 Jun 2023
13 Jun 2023
Confirmed allegations of inappropriate behavior towards a resident by a staff member, resulting in termination.
27 Mar 2023
27 Mar 2023
Found no deficiencies during the annual visit; resident and staff records were current, safety measures and medication handling were in order, and security for chemicals and cleaning supplies was in place. Administrative forms were requested to be updated.
27 Mar 2023
27 Mar 2023
Reviewed during the visit: resident and staff files, medication storage, first aid kit, activity areas, kitchen, storage areas, resident bedrooms, restrooms, laundry area, memory care unit, exterior grounds, fire safety measures. No deficiencies observed.
20 Oct 2022
20 Oct 2022
Found that the allegations of dirtiness, odors, bedding and clothing cleaning issues, and delayed communication with residents' representatives were not supported by evidence. Interviews with residents, staff, and family members, along with housekeeping records, showed rooms and common areas were kept clean and no deficiencies were observed.
20 Oct 2022
20 Oct 2022
Investigated allegations of an unsanitary environment, odor issues, insufficient cleaning of bedding and clothing, and poor communication were found unsubstantiated due to a lack of evidence. No deficiencies observed or cited during the visit.
§ 87468.1(a)(1)
07 Sept 2022
07 Sept 2022
Found that the allegation that staffing was insufficient to meet residents' needs and that residents were left unattended was unsubstantiated.
07 Sept 2022
07 Sept 2022
Identified lack of an active administrator on site and no notice of a change of administrator; interviews and LIC 500 showed no designated administrator present.
§ 87405
07 Sept 2022
07 Sept 2022
Cited deficiencies for lack of active administrator on site during unannounced visit.
16 Jun 2022
16 Jun 2022
Investigated on June 16, 2022 found the retaliation against a resident UNSUBSTANTIATED, the HIPAA violation UNFOUNDED, and the Resident Council regulation allegation UNSUBSTANTIATED.
16 Jun 2022
16 Jun 2022
Identified an allegation that an administrator told a resident that if he continued to file complaints, she would cause him to lose his job. Observed a resident council meeting where residents discussed concerns about how things are run.
§ 87468.2
16 Jun 2022
16 Jun 2022
Investigated complaints of administrator retaliation against a resident, violation of HIPAA laws, and resident council regulations. Retaliation and council regulation allegations found unsubstantiated due to lack of evidence, and the HIPAA violation claim was deemed unfounded based on resident consent for medical information access.
29 Apr 2022
29 Apr 2022
Investigated a complaint that food was not kept hot during meals; found kitchen staff kept food hot during service, with a resident stating cold meals occurred only during a COVID outbreak when meals were delivered to rooms and improvements were made since, therefore the complaint was determined unsubstantiated.
29 Apr 2022
29 Apr 2022
Found no evidence that residents were unsafe at this home; front-desk access controls, added lighting, and staff training supported a safe environment, and police calls over the past year showed no safety-related issues.
Found no evidence of short staffing; residents and administration reported adequate coverage, staff were professional, food quality was generally good with some individual concerns, and pendant systems were tested and found to work.
29 Apr 2022
29 Apr 2022
Confirmed allegations related to safety, staffing, professionalism, food quality, and pendant functionality were found to be unsubstantiated after interviews and record reviews were conducted.
22 Apr 2022
22 Apr 2022
Found no deficiencies at this home today; 117 residents (including 5 on hospice) were present and medications were securely stored. Fire safety and health measures were in place, including working smoke and carbon monoxide detectors, a current fire extinguisher, completed disaster drills, water at 107 degrees, a complete first aid kit, locked toxins, and adequate food supplies.
22 Apr 2022
22 Apr 2022
Inspection found no deficiencies and all regulations were met.
24 Mar 2022
24 Mar 2022
Investigated and found a strong urine odor in the memory care hallway indicating disrepair; other allegations—retaliation against a resident, staff disrespect, and charging for services not provided—were not supported by the evidence.
24 Mar 2022
24 Mar 2022
Investigated two allegations: that the administrator is not of good character and that bed bugs were present. Found that staff generally described the administrator as good, with some residents expressing concerns; bed bug issue was limited to one room.
24 Mar 2022
24 Mar 2022
Determined no issues with Administrator's character after speaking with staff and residents. Bed bug concerns addressed promptly by facility staff and exterminator. No deficiencies found during the visit.
10 Jan 2022
10 Jan 2022
Found the allegation that there was not enough staff to serve breakfast in a timely manner not supported by records or resident feedback. Review of the two-week server schedule showed two servers for breakfast daily, and interviews with four residents reported no concerns about breakfast timing.
10 Jan 2022
10 Jan 2022
Reviewed the allegations of insufficient staff to serve breakfast on time and found no evidence to support the claim. No deficiencies were cited during the visit.
§ 87303(a)(1)
28 Dec 2021
28 Dec 2021
Found the allegation that resident council members were not allowed to be interviewed during an inspection process unsubstantiated.
28 Dec 2021
28 Dec 2021
Found that separate activities were provided for different care communities, dining hours complied with regulations, transportation was available through multiple options, and hospice care needs were being met; no evidence supported the allegations.
28 Dec 2021
28 Dec 2021
Confirmed that resident council members were allowed to be interviewed during inspections in the past and provided a private meeting space for interviews.
17 Dec 2021
17 Dec 2021
Reviewed that the executive director acknowledged receipt of the response to resolution meeting requests and sent a letter to resident leadership requesting a meeting. Noted that resident council agreed to the meeting and confirmed a time with the executive director, and that the ED was to review past written concerns and provide a written response.
01 Dec 2021
01 Dec 2021
Found the rate increase notice did not meet regulatory notice requirements and lacked acceptable justification. Found that written responses to Resident Council concerns were not provided within 14 days; interviews with Resident Council members during the review were not supported by records.
17 Dec 2021
17 Dec 2021
Reviewed concerns and recommendations submitted by residents, met with Resident Council to discuss issues and schedule a meeting with the Executive Director.
01 Dec 2021
01 Dec 2021
Found no deficiencies cited today; observed PPE supplies and extra gloves available, meals served with no more than four residents per table, medications locked and properly disposed of, and quarterly audits conducted.
01 Dec 2021
01 Dec 2021
Investigated an AWOL incident on 11/7/21 and found that a resident left unassisted, was located in the parking lot, and returned the same day.
01 Dec 2021
01 Dec 2021
Confirmed allegation of a resident leaving the facility unassisted, resulting in an incident that required medical attention.
§ 1569.655(a)
§ 1569.1579(c)
09 Nov 2021
09 Nov 2021
Identified a bed bug infestation in multiple rooms and the allegation that an incident report was not submitted.
09 Nov 2021
09 Nov 2021
Confirmed presence of bed bugs and cited deficiencies during the visit.
§ 87411(a)
§
23 Aug 2021
23 Aug 2021
Found no deficiencies after a case management follow-up regarding an incident on 08/10/2021 involving two residents; observed organized activity areas with calendars and materials ready for engagement.
23 Aug 2021
23 Aug 2021
Determined there was insufficient evidence to prove the allegation that there was not enough staff to meet residents’ needs during meals.
23 Aug 2021
23 Aug 2021
Determined allegation of insufficient staffing to meet residents' needs was unsubstantiated after reviewing interviews and documentation, with no conclusive evidence found to support the claim.
§ 80061(b)(1)
§ 80087
19 Aug 2021
19 Aug 2021
Found a history of staffing and care concerns plus a past complaint alleging violations, with leadership changes underway. No deficiencies were cited on this date.
19 Aug 2021
19 Aug 2021
16 violations were identified during the visit, but no deficiencies were cited.
28 Jul 2021
28 Jul 2021
Found that residents did not feel safe due to increased altercations, and that food handling was unsafe, with several dishes left uncovered and meals served late.
§ 87555(b)(9)
§ 87411(a)
28 Jul 2021
28 Jul 2021
Confirmed residents did not feel safe and food was not handled safely at the facility.
19 Jul 2021
19 Jul 2021
Found that staff were not sufficient to meet residents' needs, residents did not feel safe, food handling was unsafe, and the menu was not followed. The allegation that a resident was forced to eat on the floor was unfounded, and the allegation about residents not receiving showers was unsubstantiated.
§ 80078(a)
§ 87555(b)(6)
19 Jul 2021
19 Jul 2021
Found kitchen equipment was in disrepair and resident supervision was inadequate. Could not confirm claims that staff handled residents roughly or retaliated against reporters, and could not confirm that residents were not given showers.
§ 80087(a)
§ 87705(4)
19 Jul 2021
19 Jul 2021
Investigated and identified that the allegation that staff were not associated with the home occurred, based on interviews and records reviewed. A deficiency was cited for this issue.
19 Jul 2021
19 Jul 2021
Confirmed kitchen equipment issues and lack of supervision of residents, but found no evidence of staff retaliation.
01 Jul 2021
01 Jul 2021
Identified that a deficiency cited on 6/16/2021 was cleared, with civil penalties still pending. Observed an unlocked cleaning cart in the main hallway on the second floor that would not lock, dirty carpets in the stairways, and windows with cobwebs, concerns previously raised by residents.
01 Jul 2021
01 Jul 2021
Found no evidence that staff failed to provide showers for residents. Found that meals were not served due to staffing/scheduling and that staff did not respond to residents’ calls for assistance.
§ 87411(a)
§ 87411(a)
01 Jul 2021
01 Jul 2021
Identified deficiencies in fire safety and cleanliness were observed during the visit.
16 Jun 2021
16 Jun 2021
Identified that residents engaged in multiple physical altercations with other residents and that staffing levels were insufficient, risking residents' health and safety.
§ 87705(c)(4)
16 Jun 2021
16 Jun 2021
Identified an outdated fixed fire suppression system last serviced in 2019 and an unlocked cleaning chart in the main hallway.
Cited deficiencies and assessed civil penalties.
16 Jun 2021
16 Jun 2021
Confirmed multiple physical altercations between residents and understaffing at the facility.
§ 87355(e)
07 May 2021
07 May 2021
Identified that staff did not meet residents' needs during the investigation.
12 Apr 2021
12 Apr 2021
Found unlocked toxins accessible to residents in common areas and in their rooms. Secured and locked the toxins during the visit.
§ 80087(g)(1)
07 May 2021
07 May 2021
Confirmed that staff did not meet resident needs.
§
§ 80087(a)
12 Apr 2021
12 Apr 2021
Observed deficiencies in the facility related to accessible toxins in common areas and resident rooms during the visit. Locked and secured toxins after observations were made.
§ 87203
§
23 Feb 2021
23 Feb 2021
Identified that resident meals were not of good quality or sufficient quantity and were served late on several occasions due to staffing and scheduling issues. Interviews with residents and other witnesses supported these findings, and prior leadership acknowledged complaints about meal delivery to rooms in line with Local Health Department requirements.
23 Feb 2021
23 Feb 2021
Determined food quality and quantity for residents were insufficient and meals were served late due to staffing issues, with allegations confirmed as valid.
§ 87618(b)(5)
05 Nov 2020
05 Nov 2020
Identified a deficiency for failure to document bruises and discolorations on a resident's arms, with hospice staff first noting marks on 6/26/2020 and management unaware until 6/29/2020. Direct care staff reported not observing marks needing documentation, shift notes did not document skin conditions, and an exit interview was conducted with appeal rights issued.
05 Nov 2020
05 Nov 2020
Found that there was not a preponderance of evidence to prove Neglect/Lack of Care; interviews with staff and care monitors did not reveal any actions explaining injuries, and the alleged victim could not be interviewed because she had died.
05 Nov 2020
05 Nov 2020
Investigated allegation of neglect/lack of care, but could not substantiate. No deficiencies found.
§ 87555(b)(8)
§ 87555(b)(18)
13 Mar 2020
13 Mar 2020
Inspection identified deficiencies in storing toxins in a resident's room.
§
27 Dec 2019
27 Dec 2019
Confirmed that employees who were not supposed to be working at the facility were found working and have been removed from their positions until proper clearance is granted.
