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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200082
Report Date: 04/30/2024
Date Signed: 04/30/2024 10:56:55 AM

Document Has Been Signed on 04/30/2024 10:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROYAL COLONY IN BERKELEYFACILITY NUMBER:
019200082
ADMINISTRATOR/
DIRECTOR:		ALEGRE, FELIX JAMESFACILITY TYPE:
735
ADDRESS:1606 ALCATRAZ AVE.TELEPHONE:
(510) 655-8221
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 32CENSUS: 24DATE:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH: Felix James Alegre, Manager/Administrator (ADM)TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 04/30/24 around 09:30 AM, L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management. LPA met with Felix James Alegre, Manager/Administrator (ADM), and explained the purpose of the visit.

On 04/29/24, LPA received an LIC624A regrading the death of Client #1 (C1) on 04/26/24. LPA reviewed C1’s files, interviewed Administrator (ADM) and requested information and documentation including but not limited to relevant incidents that may have occurred prior to C1’s death, LIC624s, care note, case notes, most recent Physician’s Report/Medical Assessment, ID/Emergency contact information and requested the death certificate once available.

On 04/17/24, C1 told the facility Staff #1 (S1) that he/she was not feeling well and couldn't stand up. When S1 was assisting C1 with eating breakfast, and suddenly C1 vomited. S1 called 911 for further evaluation. Around 8:10 PM, Witness #1 (W1) from Alta Bates spoke to S2, and stated that C1 would be staying overnight in the hospital, and it would probably take three days for observation.

......continued on LIC809C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROYAL COLONY IN BERKELEY
FACILITY NUMBER: 019200082
VISIT DATE: 04/30/2024
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...continued from LIC809

On 04/24/2024, W2 informed S2 Regarding C1’s assessments; C1 cannot swallow food and also needs assistance in transferring.

On 04/27/24, W3 and W4 called the facility around 8:45 AM and informed S2 at Royal Colony in Berkeley that C1 passed away last night on 04/26/24 around 10:00 PM. S2 stated that C1 has lived at the facility since about 2009; the family will retrieve C1's items on or around 05/01/24 and donate some of the items to the facility if needed.

No deficiencies cited. Exit Interview conducted and a copy of this report provided to ADM.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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