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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200082
Report Date: 09/09/2025
Date Signed: 09/09/2025 11:31:42 AM

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
09/02/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250902084129
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: 20DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:James Alegre, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff do not ensure resident receives medications as prescribed
Staff do not ensure residents room is kept in clean sanitary condtions
INVESTIGATION FINDINGS:
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On 09/09/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with and explained the purpose of the visit to James Alegre, Administrator (ADM).

During the investigation, LPA and ADM toured C1's room, LPA captured photos, and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, House Rules, current Appraisal Needs and Services, and Admission Agreement.

Allegations SUBSTANTIATED:

Continued on LIC809C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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-20250902084129
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: 09/09/2025
NARRATIVE
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...continued from LIC809.

Staff do not ensure residents room is kept in clean sanitary conditions
On 08/22/2025, LPA and S1 toured C1’s room. LPA observed a red solo plastic cup filled with an unknown substance that attracted what appeared to be a swarm of gnats, two of the drawers in Chester of Drawers were missing, the white wall light fixture was covered with what appeared to be dust, and an unknown substance that was textured and brown in color was splattered on two of the walls in multiple places. Although S1 stated the facility was undergoing repairs, the licensee did not ensure maintenance of C1’s room for furniture, equipment and hygiene.

Staff do not ensure resident receives medications as prescribed
C1’s Medication Administration Record (MAR) dated 08/01/2025 report that C1’s Olanzapine medication was not administered at 08:00 AM. due to hospitalization; however, C1’s progress notes at 02:30 PM revealed C1 was transported to Alta Bates Hospital in Berkeley, CA. and at 07:59 PM Alta Bates Hospital Emergency Room contacted the facility inquiring about C1’s medication; Olanzapine was due at 05:00 PM.

Based on the above observation, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached 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. A copy of this report and appeal rights were provided to James Alegre, ADM.

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

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250902084129
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: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2025
Section Cited
CCR
85075(b)
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85075 Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
This requirement was not met as evidenced by:
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Licensee to create an emergency binder for Clients medical services, review regulations and provide signatures of in-service training for all staff by POC date.
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Based on observation, interviews and records reviewed, the licensee did not comply with the section cited above by not meeting C1’s medical needs which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type B
09/23/2025
Section Cited
CCR
85088(c)
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85088 Fixtures, Furniture, Equipment and Supplies (c) The licensee shall ensure provision to each client...furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. -This requirement was not met as evidenced by:
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Licensee to disinfect C1’s room, repair/peplace furniture and review regulations. Provide phtos and signatures of in-service training for all staff by POC date.
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Based on observation and interviews, the licensee did not comply with the section cited above by not maintaining C1’s room furniture, equipment and hygiene. which poses/posed 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: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
09/02/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250902084129

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: 20DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:James Alegre, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff allowed resident to be left in soiled clothing for an extended period of time
Staff do not ensure resident is observed for changes in his health condition
Staff did not ensure resident was free of mal odors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
On 09/09/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with and explained the purpose of the visit to James Alegre, Administrator (ADM).

During the investigation, LPA and ADM toured C1's room, LPA captured photos, and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, House Rules, current Appraisal Needs and Services, and Admission Agreement.

Allegations UNSUBSTANTIATED:

Continued on LIC809C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250902084129
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: 09/09/2025
NARRATIVE
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Allegations UNSUBSTANTIATED:
Staff allowed resident to be left in soiled clothing for an extended period of time.
C1’s psychiatric evaluation dating back to 09/29/2015 recording C1’s refusal to any meaning interaction, refused to discuss anything, and was covered in feces. S1 and W2 stated that C1 is very Stubborn. S1 noticed C1's schedule was off; C1 normally goes out on his/her own and do not know what happened with C1's hip. S1 took food to C1's room and told C1 they would call the doctor because the Clients are not supposed to eat in the rooms. C1 also stated that he/she did not want to talk to his/her Case Manager but agreed to be transported to Alta Bates Hospital in Berkeley, CA.

Staff do not ensure resident is observed for changes in his health condition
C1’s psychiatric evaluation dating back to 09/29/2015 recording C1’s refusal to any meaning interaction, refused to discuss anything, and was covered in feces. S1 and W2 stated that C1 is very Stubborn. C1’s LIC602 dated 10/02/2024 states that C1 is able to bathe C1’s own self and needs assistance. On 11/12/2024, C1’s Health Needs and Services review notates resistive behaviors, refusal of medical interventions, an advisory of C1 following a hygiene plan to shower 2-3 times a week and change into fresh clothes. On 04/17/2025, Appraisal/Needs and Services Plan states that C1 is poor with ADLs and when prompted, C1 refuses to shower. W2 stated that C1 is not conserved and refuses to talk to the doctors.

Staff did not ensure resident was free of mal odors
C1’s psychiatric evaluation dating back to 09/29/2015 recording C1’s refusal to any meaning interaction, refused to discuss anything, and was covered in feces. S1 and W2 stated that C1 is very Stubborn. C1’s LIC602 dated 10/02/2024 states that C1 is able to bathe C1’s own self and needs assistance. On 11/12/2024, C1’s Health Needs and Services review notates resistive behaviors, refusal of medical interventions, an advisory of C1 following a hygiene plan to shower 2-3 times a week and change into fresh clothes. On 04/17/2025, Appraisal/Needs and Services Plan states that C1 is poor with ADLs and when prompted, C1 refuses to shower.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided Administrator Felix James Alegre.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5