019200082-5-2-2023-15-AS-LHOS-CRG235-20230502170147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200082
Report Date: 05/02/2023
Date Signed: 05/02/2023 05:01:51 PM

Document Has Been Signed on 05/02/2023 05:01 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:	ALEGRE, FELIX JAMES		FACILITY TYPE:	735
ADDRESS:	1606 ALCATRAZ AVE.		TELEPHONE:	(510) 655-8221
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94703
CAPACITY: 32		CENSUS: 26	DATE:	05/02/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Felix James Alegre, Manager/Administrator		TIME COMPLETED:	05:15 PM

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On 05/02/23 at 4:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management visit for as unusual/injury incident report (UIR) received at the Community Care Licensing Department (CCLD) on 04/11/23. LPA met with Felix James Alegre, Manager/Administrator (ADM) and explained the purpose of the visit.

CCLD was informed that on 04/02/23 at around 12:10 PM, a nurse from Alta Bates Hospital in Berkeley, California called and informed S1 that C1 slid at an unknown walkway in the community, and they were attending to C1 at the Emergency Room. On the same day at around 2:00 PM, an Alta Bates nurse called and informed the facility that the C1 had a fractured ankle and needed surgery. At around 6:00 PM, an Alta Bates nurse called and requested a list of C1's prescribed medications, which was faxed by S1 to the hospital. On 04/10/23, a nurse from Alta Bates called and informed the facility that they would be transferring C1 to Highland Hospital for orthopedic treatment, but C1 was transferred to Jones Convalescent Hospital instead. On 04/10/23 a social worker from Jones Convalescent Hospital called the facility and informed S1 that C1 would have surgery on a later unsaid date at Alta Bates Hospital. To date and S1's knowledge, C1 has had surgery and will recover at Jones Convalescent Hospital. The facility is to perform a reappraisal prior to C1's discharge.

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: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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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