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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200082
Report Date: 09/18/2024
Date Signed: 09/18/2024 05:32:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917112538
FACILITY NAME:ROYAL COLONY IN BERKELEYFACILITY NUMBER:
019200082
ADMINISTRATOR:ALEGRE, FELIX JAMESFACILITY TYPE:
735
ADDRESS:1606 ALCATRAZ AVE.TELEPHONE:
(510) 655-8221
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY:32CENSUS: 22DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:James Alegre, Administrator TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Staff abandoned resident at hospital.
INVESTIGATION FINDINGS:
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13
On 09/18/2024 around 03:15 PM, Licensing Program Analysts (LPAs) L. Holmes and P. Manalo arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegations. LPAs met with James Alegre, Administrator (ADM) and explained the purpose of the visit.

ALLEGATION:
Staff abandoned resident at hospital.
SUBSTANTIATED

During the course of the investigation and visit, LPAs conducted interviews with Licensee, ADM, Staff (S1). LPA L. Holmes had previously requested Resident (R1)’s file including, but not limited to the following documents: Current Personnel Report (LIC500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes on 04/08/24.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20240917112538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/18/2024
NARRATIVE
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...continued on LIC9099.

On 09/12/24, LPA L. Holmes advised Juliana Taburaza that if R1 has to be returned to the facility in the event that there is not another location available, one on one resources available, and/or family assistance to aid in R1's transition to another facility. Royal Colony does have a right to exercise an unlawful detainer; however, it is not acceptable for the facility to deny R1's return. Permanent placement needs to be secured, but other safety measures are to be explored until placement happens.

On 09/18/24 around 03:45 PM, LPA L. Holmes advised Juliana Taburaza, Licensee that she needs to make arrangements for R1's return to the facility from Alta Bates Hospital in Berkeley, CA. within 24 hours.

Based on observation, deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to James Alegre, Administrator (ADM)

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

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917112538

FACILITY NAME:ROYAL COLONY IN BERKELEYFACILITY NUMBER:
019200082
ADMINISTRATOR:ALEGRE, FELIX JAMESFACILITY TYPE:
735
ADDRESS:1606 ALCATRAZ AVE.TELEPHONE:
(510) 655-8221
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY:32CENSUS: 22DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:James Alegre, Administrator TIME COMPLETED:
05:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision resulting in resident wandering away from facility on multiple occasions.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
8
9
10
11
12
13
On 09/18/2024 around 03:15 PM, Licensing Program Analysts (LPAs) L. Holmes and P. Manalo arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegations. LPAs met with James Alegre, Administrator (ADM) and explained the purpose of the visit.

ALLEGATION:
Staff did not provide adequate supervision resulting in resident wandering away from facility on multiple occasions.
UNSUBSTANTIATED

During the course of the investigation and visit, LPAs conducted interviews with Licensee, ADM, Staff (S1). LPA L. Holmes had previously requested Resident (R1)’s file including, but not limited to the following documents: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes on 04/08/24.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20240917112538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/18/2024
NARRATIVE
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...continued from LIC9099A.

For the allegation staff did not provide adequate supervision resulting in resident wandering away from facility on multiple occasions, based on R1's LIC602 dated 03/04/24 R1 was able to leave the facility unassisted; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted, Appeal Rights, and a copy of this report provided to James Alegre, Administrator (ADM)
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240917112538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
80068.5(a)(4)(A)
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80068.5 Eviction Procedures (4)Inability to meet the client's needs. (A)...as specified in... which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate as specified...
-This requirement is not met as evidenced by:
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Licensee to make arrangements to return R1 to the facility on or before POC date and schedule visit with R1’s primary physician. Licensee will close gates and doors along with redirecting R1.
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Based on observation and interviews, the licensee did not comply with the section cited above by not providing CCLD with an updated LIC602 from R1’s primary physician for the relocation of R1 which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5