Inspection Reports for Brookdale Tracy

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-06-26 regarding failure to provide written notice prior to fee increases, untimely assistance to residents, and lack of contracted services due to staffing issues.

The investigation found insufficient evidence to substantiate the allegations. Interviews and record reviews showed that the resident frequently declined assistance but was capable of contacting emergency services, and the facility maintained sufficient staffing levels. No deficiencies were cited.

The complaint was unsubstantiated. Allegations included failure to provide written notice prior to fee increases, failure to provide timely assistance, and failure to provide contracted services due to staffing shortages. Evidence did not support these claims.

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2025-05-16 regarding facility cleanliness, medication management, incident reporting, pendant system functionality, timeliness of medical attention, and infection control practices.

The investigation found no preponderance of evidence to substantiate any of the allegations. The facility was observed to be clean and sanitary, medication management was appropriate, incidents were reported as required, medical attention was timely, and infection control practices were followed. No deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included facility cleanliness, medication mismanagement, failure to report incidents, nonoperable pendant system, delayed medical attention, and infection control violations. All allegations were found to lack sufficient evidence to prove violations.

The visit was an unannounced complaint investigation conducted due to allegations that staff unlawfully evicted a resident.

The investigation substantiated that the facility staff unlawfully evicted a resident by failing to provide the eviction notice to the department within five days as required, posing potential health, safety, and personal rights risks to persons in care.

The complaint was substantiated based on observations, record reviews, and interviews, confirming that staff unlawfully evicted a resident by not providing the eviction notice to the department within the required timeframe.

The visit was an unannounced annual continuation inspection conducted to continue the annual visit from 04/29/2025 and to assess ongoing compliance with licensing requirements.

A comprehensive tour of the facility was conducted including resident rooms, common areas, kitchen, laundry, memory care unit, and exterior grounds. All safety measures, food storage, and resident accommodations were found to be adequate and in compliance. No deficiencies were observed or cited during this annual visit.

The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.

No deficiencies were observed or cited during this annual visit. The Licensing Program Analyst reviewed facility records including resident and staff files, all of which were complete and up to date. Due to insufficient time, the inspection will be completed at a later date.

The visit was an unannounced case management follow-up to review two Special Incident Reports received on 09/16/2024 and 10/24/2024 involving medication error and resident elopement incidents.

The inspection found that a medication technician administered a higher dose than prescribed to a resident and that a resident with dementia eloped from the memory care area but was safely redirected back. The facility had taken corrective actions including training and notification of family and hospice.

The visit was an unannounced case management follow-up on an incident report received on 07/15/2024 regarding a missing resident (elopement) from the facility.

The facility failed to follow its missing resident policy and did not conduct proper observation checks or a thorough search after a resident was found missing for nearly an hour. Staff did not conduct an initial head count or a full search of the memory care area, posing immediate health and safety risks.

The visit was an unannounced annual continuation inspection conducted to continue the annual visit started on 04/25/2024 and 05/09/2024, to assess compliance with licensing requirements.

The inspection found that 6 out of 14 resident files did not have a pre-appraisal assessment on file, which is required prior to admission. The facility was using a personal service assessment form that did not capture key assessment areas such as medication, service needs, ambulatory status, TB test, and social factors. A technical violation was cited under sections 87705(c)(5) and 87457(c).

The visit was an unannounced annual continuation inspection conducted to continue the annual visit from 04/25/2024.

During the visit, the Licensing Program Analyst toured the facility, reviewed 5 resident files, and found no deficiencies or citations.

The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.

The inspection found no deficiencies or violations during the visit. The facility was observed to be in compliance with safety, medication management, and resident care standards, although a technical violation was noted for 8755(b)(26).

The visit was an unannounced case management follow-up to review multiple incident reports received by the department via fax on various dates between 12/20/2022 and 1/09/2024.

Based on interviews and records reviewed during the visit, no deficiencies were found.

The visit was conducted as an unannounced Plan of Correction (POC) follow-up to verify that prior deficiencies and plan of corrections due on 11/17/2023 from a complaint visit on 11/09/2023 had been met.

The Plan of Correction was reviewed and found to be met and cleared. No deficiencies were cited during this visit.

The visit was conducted as a follow-up on two incident reports received by the department on 11/02/2023 and 11/22/2023.

The facility conducted internal investigations on both incidents; one involving missing resident cash and the other involving delayed staff response to a resident's call for help. Additional staff training and corrective actions were implemented. No deficiencies were cited during this visit.

The visit was an unannounced complaint investigation conducted due to allegations that the facility did not follow its emergency plan during power outages, did not ensure residents' oxygen was operable, and had multiple power outages.

The investigation substantiated that the facility did not follow its emergency plan during power outages on 09/03/2023 and 09/04/2023, lacking emergency lighting, working elevators, and generator availability. The allegation that the facility did not ensure residents' oxygen was operable was unsubstantiated, and the allegation of multiple power outages was found unfounded. One deficiency was cited related to emergency preparedness.

The complaint investigation included three allegations: failure to follow emergency plan during power outages, failure to ensure residents' oxygen was operable, and multiple power outages. The first allegation was substantiated, the second was unsubstantiated, and the third was unfounded.

The visit was a case management visit initiated by the licensee in response to a phone call received regarding resident R1.

No deficiencies were cited during this case management visit. An interview was conducted with the Facility Designated Administrator, and documentation regarding R1 will be obtained via email.

The visit was conducted as a follow-up on an incident report received on 08/16/2023 regarding a medication count discrepancy involving resident R1's antibiotic medication.

The inspection found a technical violation related to medication administration where the Medication Administration Record was signed after administration but the medication count was incorrect. The responsible staff member was terminated after multiple incidents of unaccounted medication.

The visit was conducted to follow up on an incident report received on 2023-09-13 regarding an allegation that resident R1 was hit by resident R2 a few days prior to notifying staff.

Based on interviews and observations, no deficiencies were cited during this visit. Facility staff did not observe any redness or indications that R1 was hit, and R1 was unable to explain the injury at the time of interview.

The complaint involved an allegation that resident R1 was hit by resident R2. The allegation was investigated through interviews and observation, and no substantiated deficiencies were found.

The visit was a case management follow-up on an incident report received on 2023-09-22 regarding concerns about a resident's Power of Attorney and potential financial abuse.

Based on interviews conducted during the visit, there were no concerns or evidence of financial abuse by the resident's Power of Attorney. No deficiencies were cited during this visit.

The complaint involved a resident notifying staff that they closed their account due to uncertainty about their Power of Attorney's handling of their money. The investigation found no substantiated financial abuse.

The visit was an unannounced case management follow-up to an incident report received by the department regarding a resident expressing self-harm intentions.

The Licensing Program Analyst conducted interviews and reviewed relevant records, resulting in a Technical Violation issued for Section 87705(f)(1).

The visit was an unannounced case management follow-up on an incident report received by the department involving two residents in memory care.

Based on interviews and facility records reviewed during the visit, no deficiencies were cited. The Licensing Program Analyst will return if further follow-up is needed.

The visit was triggered by a special incident report received on 2023-05-26 regarding an incident where one resident pushed another into their wheelchair. The incident was investigated and found to have no resulting deficiencies.

The visit was an unannounced case management follow-up to an incident report received by the department regarding an incident between three residents in memory care.

Based on interviews and facility records reviewed during the visit, no deficiencies were cited. The facility had appropriately monitored and managed the incident involving the residents.

The visit was triggered by a special incident report received on 2023-05-16 involving an altercation between three residents. The complaint was investigated and found to have no deficiencies.

The visit was conducted as a case management follow-up on a facility-reported incident received by the department on 2023-05-25 involving staff misconduct.

The investigation confirmed that staff member S1 smacked resident R1 during care, violating personal rights. S1 was removed from the staffing schedule pending investigation and subsequently terminated. The facility was cited for failure to ensure residents were treated with dignity and respect.

The complaint investigation was substantiated based on interviews and record review confirming staff misconduct. Staff member S1 was terminated on 2023-05-15 following the incident.

The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements and overall operation.

No deficiencies were observed or cited during this annual visit. The facility was found to have current resident and staff files, proper medication storage and administration, adequate safety measures, and sufficient furnishings and supplies.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-08-22 alleging the facility was unsanitary, odiferous, dirty, staff were not cleaning resident bedding or changing resident clothing, and that communication requests by resident representatives were not timely responded to.

After interviews with residents, staff, and family members, and review of housekeeping and laundry schedules, the investigation found insufficient evidence to substantiate the allegations. The facility was found to be clean and sanitary with routine cleaning and laundry services. Communication with resident representatives was generally timely. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint was unsubstantiated. Although allegations may have occurred, there was not a preponderance of evidence to prove the violations. No deficiencies were observed or cited.

The visit was an unannounced case management follow-up to address the facility's lack of an active administrator after the previous administrator left on 07/29/2022.

The facility has not had an active administrator since 07/30/2022, which poses immediate health, safety, and personal rights risks to residents. Deficiencies were cited related to the absence of a qualified and currently certified administrator.

The visit was conducted to investigate a complaint received on 2022-07-08 alleging insufficient staffing to meet residents' needs and staff leaving residents unattended.

After interviews with eight residents, eight staff members, and two family members, the investigation found no sufficient evidence to substantiate the allegations. Residents and family members reported satisfaction with care and no issues with staff leaving residents unattended. No deficiencies were cited.

The complaint was unsubstantiated. Although allegations may have happened or been valid, there was not a preponderance of evidence to prove the alleged violation occurred.

An unannounced Case Management - Deficiencies visit was conducted to investigate issues related to resident complaints and concerns about the facility's operations.

The inspection found that statements were made by facility staff that could deter residents from filing complaints, posing a potential threat to the health, safety, or personal rights of residents in care.

The visit was complaint-related, triggered by previous interviews indicating that the Administrator told a resident that continued complaints could result in her losing her job, which could be interpreted as deterring residents from filing complaints with state licensing.

An unannounced complaint investigation visit was conducted to investigate allegations including retaliation by the facility administrator against a resident, violation of Resident Council regulations, and violation of HIPPA laws.

All allegations were found to be unsubstantiated or unfounded after interviews and record reviews. No deficiencies were cited during the visit per Title 22 Regulations.

The complaint investigation was triggered by allegations that the facility administrator retaliated against a resident, violated Resident Council regulations, and violated HIPPA laws. The investigation found no evidence to substantiate these allegations.

An unannounced complaint investigation was conducted to investigate allegations that the facility does not keep food hot during meal service.

The investigation found that the facility kitchen staff is keeping the food hot during meal service. A resident reported past issues during a COVID outbreak when food was delivered to rooms, but stated the issue is no longer present. The kitchen manager addressed resident concerns and made improvements such as ordering black plates and heat lamps to keep food warm. The complaint was unsubstantiated and no deficiencies were cited.

The complaint alleged that the facility does not keep food hot during meal service. The complaint was found to be unsubstantiated based on interviews and observations.

The visit was an unannounced complaint investigation conducted to address multiple allegations including unsafe environment, unprofessional staff, malfunctioning pendants, short staffing, and food quality concerns at the facility.

The investigation found all allegations to be unsubstantiated based on interviews with staff, residents, and review of records including police calls and pendant testing documents. The facility was found to provide a safe environment, adequate staffing, professional staff, functioning pendants, and good quality food.

The complaint investigation addressed allegations that the facility does not provide a safe environment, staff are unprofessional, pendants do not work properly, the facility is short staffed, and food quality issues. All allegations were found to be unsubstantiated after interviews and record reviews.

An unannounced visit was conducted for the facility's annual inspection to evaluate compliance with regulations.

The inspection found the facility to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies were observed or cited during the inspection.

Unannounced complaint investigation visit to investigate allegations including retaliation against a resident for filing a complaint, staff disrespect, charging for services not provided, and facility disrepair.

The investigation found the allegations of retaliation, staff disrespect, and charging for services not provided to be unsubstantiated. However, the complaint regarding facility disrepair was substantiated due to the strong urine odor in the memory care carpeted hallway, posing a potential health and safety risk.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Sarah Hurt. Allegations included retaliation against a resident for filing a complaint, staff disrespect, charging for services not provided, and facility disrepair. The first three allegations were found unsubstantiated due to lack of preponderance of evidence, while the disrepair allegation was substantiated based on LPA observation.

The visit was an unannounced complaint investigation conducted in response to allegations received on 02/24/2022 regarding bed bugs in the facility, the character of the administrator, and the facility's procedures for handling insect reports.

The investigation found all allegations to be unsubstantiated. The administrator was found to be of good character based on staff and resident interviews. The facility had recently treated a room for bed bugs and took appropriate containment actions. The facility followed procedures adequately when insect reports were received, and no deficiencies were cited.

The complaint investigation was unsubstantiated for all allegations: bed bugs presence, administrator character, and procedural compliance regarding insect reports. Evidence did not prove violations occurred.

The visit was an unannounced complaint investigation conducted in response to an allegation that the facility did not have sufficient staff to serve breakfast in a timely manner.

The investigation found that the facility had sufficient staff to serve breakfast timely based on staff schedules and resident interviews. The allegation was deemed unsubstantiated and no deficiencies were cited during the visit.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was that the facility did not have sufficient staff to serve breakfast in a timely manner.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2021-11-04 regarding the allegation that the facility failed to allow resident council members to be interviewed during the inspection process.

The investigation found that the allegation was unsubstantiated. Records and interviews confirmed that resident council members were allowed to be interviewed during past inspections and the facility provided a private meeting space for such interviews.

The complaint alleged that the facility failed to allow resident council members to be interviewed during the inspection process. The allegation was found to be unsubstantiated based on interviews and record reviews.

The visit was an unannounced complaint investigation triggered by multiple allegations including failure to provide separate activities for different communities, reduced mealtime hours, lack of transportation for residents, and unmet needs of residents in hospice care.

All allegations were found to be unsubstantiated. The facility provided separate activities for different communities, maintained appropriate mealtime hours within regulations, offered multiple transportation options for residents, and adequately met the needs of residents in hospice care as confirmed by interviews, observations, and record reviews.

The complaint investigation was unsubstantiated based on interviews, observations, and record reviews. There was no preponderance of evidence to prove the allegations occurred as reported.

The visit was conducted to deliver an Amended Report and clear a citation, as part of a Plan of Correction (POC) unannounced visit.

The Licensing Program Analyst observed the Resident President meeting with the Executive Director to confirm receipt of the response letter regarding resolution meeting requests. The Resident Council agreed to the meeting and confirmed the time with the Executive Director. The Executive Director provided a written response to past resident council concerns as required by the POC.

The inspection was an unannounced required one-year visit to evaluate compliance with regulations and deliver findings related to allegations.

The Licensing Program Analyst inspected various facility areas including physical plant, Memory Care, and Assisted Living communities, reviewed staff and resident vaccination records, and observed compliance with safety and health protocols. No deficiencies were cited in violation of California Code of Regulations.

The inspection was an unannounced complaint investigation visit triggered by allegations including failure to allow resident council members to be interviewed, improper rate increase notice, and failure to respond to Resident Council written requests.

The allegation that the facility failed to allow resident council members to be interviewed was unsubstantiated. However, the allegation that the facility failed to respond in writing to Resident Council written requests within 14 calendar days was substantiated. Additionally, the facility increased rates without proper notice as the reasons provided did not meet regulatory requirements.

The complaint investigation was triggered by allegations that the facility failed to allow resident council members to be interviewed during the inspection process, increased rates without proper notice, and failed to respond to Resident Council written requests. The first allegation was unsubstantiated, while the latter two were substantiated.

The inspection was an unannounced Case Management Visit regarding a reported AWOL incident involving a resident that occurred on 2021-11-07.

The investigation substantiated the allegation that the resident left the facility unassisted, which posed an immediate health and safety risk. Deficiencies were cited related to personnel sufficiency and timely incident reporting.

The complaint investigation was substantiated based on interviews and record review regarding the AWOL incident of resident R-1 on 2021-11-07.

Licensing Program Analyst Arlene Garcia conducted a case management visit to investigate bed bug infestation reported by the facility.

Bed bugs were substantiated in multiple rooms, confirmed by pest control services. The facility failed to report the infestation to the licensing agency as required, posing a potential health risk to residents.

An unannounced complaint investigation was conducted due to an allegation that the licensee failed to have sufficient staff to meet the needs of the residents.

The investigation included interviews, observations, and record reviews. It was found that there was sufficient staff to meet residents' needs during meal service, and residents interviewed did not report concerns about staffing shortages. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The complaint alleged insufficient staffing to meet residents' needs, specifically noting residents having to wait over an hour for meal service. The allegation was found to be unsubstantiated.

An unannounced case management visit was conducted to follow up on an incident that occurred on 08/10/2021 involving residents R1 and R2.

No deficiencies were observed or cited during the case management inspection. The department closed the case management with no further investigation required after reviewing resident files, observing activities, and confirming proactive measures were in place.

An informal conference was conducted to discuss the high volume of deficiencies, complaints, and inability to remain in substantial compliance with regulations over the last 2 years.

No deficiencies were cited during this visit. The facility is undergoing management transition and recovery efforts including staff training and operational improvements. Various concerns such as staffing, care, supervision, security, and maintenance were discussed with plans for ongoing improvements.

An unannounced complaint investigation visit was conducted following allegations that residents do not feel safe and that facility food is not being handled in a safe manner.

The investigation found substantiated evidence that residents did not feel safe due to increased altercations in memory care, and that food prepared for dinner service was not properly covered, violating food safety regulations.

The complaint investigation was substantiated, meaning there was a preponderance of evidence to prove the allegations true as reported.

An unannounced complaint investigation was conducted in response to allegations that staff were not associated with the facility, the administrator was not designated to the facility, and the acting administrator was not qualified to manage the facility.

The allegation that staff were not associated with the facility was substantiated based on interviews and records reviewed. The allegation that the administrator was not designated and the acting administrator was not qualified was found to be unsubstantiated.

The complaint was substantiated regarding staff not being associated with the facility. The allegations about the administrator designation and qualifications of the acting administrator were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-06-09 regarding kitchen equipment disrepair and inadequate supervision of residents, as well as allegations of rough handling of residents and retaliation against complainants.

The investigation substantiated the allegations that kitchen equipment was in disrepair and staff were not providing appropriate supervision of residents, citing deficiencies related to staffing and facility maintenance. The allegations that staff handled residents roughly and that the facility retaliated against complainants were found to be unsubstantiated.

The complaint investigation was substantiated for kitchen equipment disrepair and inadequate supervision, with a preponderance of evidence supporting these allegations. The allegations of rough handling of residents and retaliation against complainants were unsubstantiated due to lack of evidence and inability to interview relevant parties.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations including insufficient staff to meet residents' needs, residents feeling unsafe, improper food handling, failure to follow the menu, lack of incontinent care, and staff misconduct.

The investigation substantiated allegations that staff was insufficient to meet residents' needs, residents did not feel safe due to altercations, food was not handled safely, and menus were not properly followed. The allegation regarding lack of incontinent care was unsubstantiated, and the allegation of staff forcing a resident to eat on the floor and poor management by the administrator was unfounded.

The complaint investigation was substantiated for allegations of insufficient staffing, resident safety concerns, unsafe food handling, and failure to follow menus. The allegation of staff not providing incontinent care and lack of supplies was unsubstantiated. The allegation that staff forced a resident to eat on the floor and poor facility management was unfounded.

Unannounced plan of correction (POC) visit to verify correction of citations issued during the case management visit conducted on 2021-06-16.

The deficiency related to fire safety cited on 2021-06-16 was cleared, but civil penalties are still pending. An unlocked cleaning cart was observed unattended and could not be locked, and dirty carpets and cobwebs were noted throughout the facility. Deficiencies were cited and civil penalties assessed for repeat violations.

The inspection was an unannounced complaint investigation visit triggered by allegations including facility staff not providing resident showers, residents' meals not served due to lack of staffing/scheduling, and staff not responding to residents calling for assistance.

The allegation that facility staff were not providing resident showers was found to be unsubstantiated after review of shower schedules and interviews. However, the allegations that residents' meals were not served timely due to staffing issues and that staff were not responding promptly to residents' calls for assistance were substantiated. Deficiencies related to personnel requirements and call system functionality were cited.

The complaint investigation was initiated based on allegations received on 06/01/2021. The allegation that facility staff were not providing resident showers was unsubstantiated. The allegations that residents' meals were not served due to lack of staffing/scheduling and that staff were not responding to residents calling for assistance were substantiated. The Nurse Call System was found to be malfunctioning, contributing to delayed responses.

The inspection was an unannounced complaint investigation visit triggered by allegations that residents were engaging in multiple physical altercations and that the facility was understaffed.

The investigation substantiated the allegations of multiple physical altercations among residents and understaffing. Several altercations were documented with one resident requiring emergency room care. The facility was found to have an inadequate number of direct care staff, posing an immediate risk to resident health and safety.

The complaint investigation was substantiated based on interviews, record reviews, staff schedules, and timesheets. Multiple resident altercations were confirmed, including incidents on 5/30/21, 5/16/21, and 4/26/21. The facility was found to be understaffed, placing residents at risk for further injury or hospitalization.

The inspection was an unannounced complaint investigation initiated by Licensing Program Analysts Albert Johnson and Arlene Garica to assess compliance with regulations.

Deficiencies were observed including an outdated fixed Ansul fire safety system in the kitchen last serviced on 09/02/2019, and an unlocked cleaning chart in the main hallway posing an immediate health and safety risk. Civil penalties were assessed.

The visit was triggered by a complaint investigation. Deficiencies were substantiated and civil penalties were assessed.

This was an unannounced complaint investigation visit triggered by a complaint received on 2021-04-14 alleging that staff were not meeting residents' needs.

The investigation substantiated the allegation that staff were not meeting residents' needs. A deficiency was cited for failure to ensure staff were knowledgeable and trained in the operation of oxygen equipment, posing a potential risk to residents.

The complaint alleging staff not meeting residents' needs was substantiated based on interviews and records reviewed. The investigation included interviews with the Executive Director, Nurse, and RS, and found staff lacked knowledge in oxygen equipment operation.

The visit occurred to deliver findings related to a complaint dated 03/23/2021 regarding facility safety concerns.

During the inspection, Licensing Program Analysts observed unlocked toxins accessible to residents in both common areas and resident rooms, posing an immediate health risk. The administrator secured and locked the toxins during the tour.

The visit was complaint-related, triggered by a complaint dated 03/23/2021. The complaint was substantiated by the observation of unlocked toxins posing immediate health risks.

The inspection was an unannounced complaint investigation triggered by allegations received on 12/09/2020 regarding residents' food quality, quantity, and timeliness of service.

The investigation substantiated the complaints that residents' food was not of good quality or sufficient quantity and that food was served late due to staffing and scheduling issues. These deficiencies posed potential health and safety risks.

The complaint was substantiated based on interviews with residents, staff, and witnesses, and review of facility records. The allegations involved poor food quality, insufficient quantity, and late meal service due to staffing issues.

Unannounced investigation of a complaint alleging that a resident sustained unexplained injuries due to abuse or neglect.

The investigation found the allegations to be unsubstantiated based on interviews with staff and witnesses. No deficiencies were noted or cited.

Allegation that Resident (R-1) sustained unexplained injuries while in care as a result of abuse or neglect. The allegation was unsubstantiated after investigation.

The visit was a Case Management phone call to discuss deficiencies observed during a complaint investigation related to the facility's failure to document bruises and discolorations on a resident's arms.

The facility failed to document significant bruising and skin tears on Resident R-1's hands and arms, which were first observed by hospice staff on 06/26/2020 but not reported to the physician or responsible party for about 10 days, posing a potential safety risk.

The deficiency was observed during a complaint investigation. Hospice staff first observed bruising on 06/26/2020, and the facility executive director was unaware of the marks until 06/29/2020. Direct care staff did not document or report the bruising. The deficiency was cited per California Code of Regulations, Title 22 chapter 8.