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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:15:16 PM


Document Has Been Signed on 08/22/2022 04:15 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: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: 92DATE:
08/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Tracy Gibson, Assistant Executive DirectorTIME COMPLETED:
04:30 PM
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On 08/22//2022 at 3:25 PM, Licensing Program Analysts (LPAs) L. Holmes and Meenakshi Malik conducted an unannounced case management visit pertaining to Resident #1 (R1) who eloped on 08/11/2022. On 08/09/2022, S1 sent an email to LPA L. Holmes to discuss the respite stay of R1. On 08/11/2022 prior to the elopement, LPA and S1 had a phone appointment and discussed the change in conditions, reappraisal, needs and services plan and 60-day eviction for R1. R1 does not have a history of elopement or exit-seeking behavior, and has a wander guard device which alerts staff when the resident is near an exit door. While one of the care staff was exiting the Dementia wing to the Assisted Living side, per S1, R1 dotted into another resident’s apartment, exited the sliding glass towards the right side and then returned to the left side, and was seen on the camera exiting the wrought iron gate north of the community. The El Cerrito Police Department was immediately called and S2 also drove around the community in search of R1. R1 was found by about 3 blocks away by the El Cerrito Police Department and was returned shortly after about an hour of the elopement. R1’s Responsible Party (RP) happen to be arriving around the same time. Additional staff training is being offered on what to look for in residents relating to elopement and/or evading delayed egresses as well as research for installation of additional egresses. Stuart House was referred for placement prior to this elopement. RP has agreed to relocated R1 by August 21, 2022 and R1 left the facility on 08/20/2022 with the RP.

No Deficiencies cited on this date. Exit interview conducted with Tracy Gibson, Assistant Executive Director and a copy of the report was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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