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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 05/05/2022
Date Signed: 05/05/2022 11:45:18 AM


Document Has Been Signed on 05/05/2022 11:45 AM - 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:EL CERRITO ROYALEFACILITY NUMBER:
075600575
ADMINISTRATOR:GIVENS, SONJAFACILITY TYPE:
740
ADDRESS:6510 GLADYS AVENUETELEPHONE:
(510) 234-5200
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:145CENSUS: 96DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Administrator, Sonja GivensTIME COMPLETED:
12:00 PM
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On 05/05/2022 at 09:19 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPA was greeted by one staff upon entry, screened for infection control and allowed to enter. LPA explained the purpose of the visit with the receptionist and was greeted by Administrator Sonja Givens (ADM).

Facility has a COVID-19 mitigation plan on file. LPA obtained a resident and staff roster, met the Assistant Executive Director (AED), Tracy Gibson, and discussed staffing plans with ADM. LPA observed screening station at the entry with a thermometer, hand sanitizer, masks, COVID-19 signage, and a resident, staff, and visitor sign-in log. LPA toured the facility including, but not limited to the common areas, bathrooms, kitchen, activity rooms and courtyard. LPA observed cough etiquette signs posted throughout the facility. There was a sufficient supply of 7-day perishables and 2-day supply of non-perishable foods; there is also an emergency food supply on site. All hand washing stations were equipped with soap, paper towels and 20 second hand washing signs. The hot water temperature in the shared residents' bathroom measured at 106.4 degrees Fahrenheit (F), and the common area temperature measured at 73 degrees (F). The fire extinguisher was last serviced on 03/01/2022. The smoke detectors are combined with the fire alarm system, and the carbon monoxide units were observed operational. First Aid kit complete & there is a surplus of PPE and isolation carts readily available.

The following forms are to be updated and submitted to CCLD by 05/12/2022:
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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