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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200082
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:41:54 PM

Document Has Been Signed on 04/05/2022 02:41 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 BERKELEYFACILITY NUMBER:
019200082
ADMINISTRATOR:ALEGRE, FELIX JAMESFACILITY TYPE:
735
ADDRESS:1606 ALCATRAZ AVE.TELEPHONE:
5106558221
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 32CENSUS: 29DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Manager, Felix James AlegreTIME COMPLETED:
02:55 PM
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On 04/05/2022 at 12:45 PM Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. Upon arrival LPA was greeted by Staff, Elena. LPA was introduced to the Manager, James and LPA explained the reason for the visit and that Administrator, Joseph Taburaza had given the ok at 12:17 PM on 04/04/2022 for James to sign on his behalf.

Facility has completed a COVID-19 mitigation plan and will add a COVID-19 screening questionnaire to visitor log. LPA observed two (3) staff and multiple residents at the facility. Some residents were watching television, sleeping and sitting outside.

LPA inspected the facility inside and out with Manager. LPA and Manager toured facility's kitchen, lobby area, residents rooms, and bathrooms. The facility had a 7-day supply of non-perishable foods and 2-days of perishables. Foods are purchased bi-weekly. LPA observed minimal COVID-19 signs posted due to the level of clients in care. Covered garbage cans with lids are needed in the bathrooms, and residents rooms. PPE observed; in need of additional face shields. LPA gave advisory in regards to isolation, PPE supply, screening, and mitigation practices. The hot water temperature measured 118.6 degrees Fahrenheit in the hall bathroom, First Aid kit observed complete and witnessed Manager test smoke/carbon monoxide detectors. Fire extinguisher last inspected 09/06/2016. See LIC 809D for deficiency cited.

Exit interview conducted, a copy of this report provided along with appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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Document Has Been Signed on 04/05/2022 02:41 PM - It Cannot Be Edited


Created By: Lisha Holmes On 04/05/2022 at 02:21 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: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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80087 Buildings 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.
Based on observation, the licensee did not meet this requirement, as the fire extingusiher expired 09/06/2016, which poses an immediate safety risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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Manager will send a photo and receipt of the new fire extingusher and tag to CCLD on or before 04/12/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
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