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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 09/29/2026
Date Signed: 09/29/2026 01:36:19 PM

Document Has Been Signed on 09/29/2026 01:36 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EL CERRITO ROYALEFACILITY NUMBER:
075600575
ADMINISTRATOR/
DIRECTOR:		GIVENS, SONJAFACILITY TYPE:
740
ADDRESS:6510 GLADYS AVENUETELEPHONE:
(510) 234-5200
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 145CENSUS: 94DATE:
09/29/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Sonja Givens-Thomas, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 09/29/2026 at 9:25 a.m., Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding a 60-day eviction notice that was reported to the Community Care Licensing Division (CCLD) on 09/04/2026. LPA met with Executive Director (ED) Sonja Givens-Thomas and explained the purpose of the visit.

The 60-day notice of eviction provided to Resident (R1) cited California Code of Regulations, Title 22, Section 87224(a)(3), “failure of the resident to comply with general policies of the facility.” Section 4 of R1’s admission agreement identifies the following facility policies as grounds for eviction: (a) verbal or physical abuse directed toward other residents; (e) destruction of property of the community; and (h) health conditions that require staffing levels not available in the community.

On 09/09/2026, LPA received documents requested from Assistant Executive Director (AED) Tracy Gibson. The documents provided included R1’s admission agreement dated 01/10/2023, Physician’s Report (LIC 602A) dated 2023, medication list, Appraisal Needs and Services dated 08/31/2026, Resident Appraisal dated 08/31/2026, Care and Needs Assessment/Overview dated 08/31/2026, and Identification and Emergency Information dated 01/09/2023.

LIC809-C Continued...

Bennett Fong
Lori Alexander-Washington
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EL CERRITO ROYALE
FACILITY NUMBER: 075600575
VISIT DATE: 09/29/2026
NARRATIVE
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LIC809-C (Page 2)

During the Case Management visit on 09/29/2026, LPA reviewed R1’s resident file and additional documents, including Physician’s Reports (LIC 602A) dated 12/30/2022 and 05/21/2024, Appraisal Needs and Services dated 01/13/2023 and 02/07/2026, and a SOC 341 dated 09/25/2026.

During an interview, Staff (S1) stated that R1 has demonstrated cognitive decline and behaviors that resulted in a verbal confrontation with Resident (R2), which became physical. S1 stated that the facility did not submit an Unusual Incident Report to CCLD regarding the incident. S1 further stated that the facility has a memory care unit; however, the memory care unit is currently at capacity, and R1 would need to be placed on a waiting list for admission to that unit.

LPA reviewed the 60-day eviction notice and observed that the notice did not identify an effective date of eviction. LPA also observed that the CCLD telephone number listed on the notice was incorrect. Although there was a address for Empowered Aging there was failure to include information for State Long Term Care Ombudsman for filing a complaint.

The deficiencies identified during this Case Management visit are documented on the LIC 809D and are cited pursuant to the applicable provisions of the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 09/29/2026 01:36 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/29/2026 at 12:03 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: EL CERRITO ROYALE
FACILITY NUMBER: 075600575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2026
Section Cited
HSC
1569.683

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 §1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations... the notice to quit shall include all of the following:
(1) The effective date of the eviction...(3) Information about the resident's right to file a complaint... with the State Ombudsman.
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The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date. In addition, the licensee shall rescind the eviction, notify resident, responsible party, and issue legal notice if that is still licensee’s plan.
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Based on interview and record review the licensee did not comply with the section cited above in serving R1 with an appropriate eviction notice that did not contain all items required under regulation, which poses a potential health and safety and personal rights risk to persons in care.

This requirement is not met as evidenced by:
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Type B
10/06/2026
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below.

This requirement is not met as evidenced by:
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The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.
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Based on interview and records review, the licensee did not comply with the section cited above in notifying Licensing incidents that occured with R1 including but not limited to a water flood in R1's room and water damage to other residents' rooms which poses a potential health, safety and or personal rights risks 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2026 01:36 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/29/2026 at 12:20 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: EL CERRITO ROYALE
FACILITY NUMBER: 075600575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2026
Section Cited
CCR
87463(a)

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87463 Reappraisals
(a) ...Pre-Admission Appraisal, shall be updated in writing...once every 12 months, whichever occurs first, to note significant changes in condition

This requirement is not met as evidenced by:
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The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.
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Based on records review, the licensee did not comply with the section cited above in R1's LIC625 Appraisal/Needs and Services Plan were not updated from 01/13/23 until 02/07/26, 08/31/26 that were not signed by R1 or responsible party which poses a potential health, safety and or personal rights risks to persons in care.
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Type B
10/06/2026
Section Cited
CCR87463(h)

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87463 Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
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The Administrator will read the regulation and submit self-certification that it has been read, understood and they will comply going forward to CCLD by POC due date.
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Based on records review, the licensee did not comply with the section cited above in R1's LIC602A (medical assessments) were dated 12/30/22, 05/21/24 and 12/02/25 which poses a potential health, safety and or personal rights risks 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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