019200082-4-8-2025-15-AS-LHOS-DFJVQ5-20250408163746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200082
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:40:00 PM

Document Has Been Signed on 04/08/2025 04:40 PM - 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 BERKELEY		FACILITY NUMBER:	019200082
ADMINISTRATOR/ DIRECTOR:	ALEGRE, FELIX JAMES		FACILITY TYPE:	735
ADDRESS:	1606 ALCATRAZ AVE.		TELEPHONE:	(510) 655-8221
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94703
CAPACITY: 32		CENSUS: 19	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Felix James Alegre, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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On 04/08/2025 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct annual inspection visit. LPA met with Felix James Alegre, Administrator (ADM), and explained the purpose of the visit. Licensee currently holds a certificate (#7006820735) that expires 12/31/26. The facility’s fire clearance was approved for thirty-two (32) clients; four (4) may be non-ambulatory.

Upon arrival LPA observed two (2) staff attending to residents, preparing lunch and monitoring the facility. LPA and ADM toured the facility including, but not limited to the bathroom, kitchen, common areas, dining area and courtyard. The facility consists of individual units housed by clients with proper furniture and lighting. The backyard passageways were free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 70 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the clients. Hot water temperature in the shared residents' bathroom was measured at 111.2 degrees (F). Bathroom #1 had hand washing signs, soap, toilet paper and was in operating condition. Hand washing signs, paper towels, and soap observed at all other hand washing stations. Linen and hygiene products were available for all clients. PPE, sanitizer, and paper goods remain sufficient.

...continued on LIC9099C.

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/08/2025

NARRATIVE

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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 08/05/24. Emergency Disaster Plan is updated. Safety drill was last conducted 01/09/25 and are rotational between AM and PM schedules monthly.

Four (4) staff records were reviewed, and all staff have criminal record clearances. Five (5) residents records were reviewed ADM agreed to audit all records for annual medical assessments.

-At 10:08 AM, LPA observed a shovel, rake, weed whacker, and broken planter pot stored on the right side of the building (removed during visit).
-At 10:30 AM, LPA observed a twin size mattress in the driveway at the front of the facility (removed during visit).
-At 10:19 AM Bathroom #1 window screen is missing and cobwebs on the ceiling vents.
-At 10:30 AM, LPA and ADM toured the facility and the following were observed missing or in disrepair:
No window coverings in the common area
Window screens missing from but not limited to rooms 9 and 11
Window screen and blind missing but not limited to room 15.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and a copy of this report this report provided ADM.

NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/08/2025 04:40 PM - It Cannot Be Edited

Created By: Lisha Holmes On 04/08/2025 at 04:18 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROYAL COLONY IN BERKELEY	FACILITY NUMBER: 019200082
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not maintaining the blinds, window screens and cobwebs thorough the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2025
	Plan of Correction
1 2 3 4	Licensee to update LPA on construction and completion repairs. Provide photos and signatures that all staff have read the regulations by POC.

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above by not properly storing landscaping items which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2025
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. Licensee to provide signatures that all staff have read the regulations by POC.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:

	Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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