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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600575
Report Date: 05/30/2025
Date Signed: 05/30/2025 05:22:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250506154801
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: 99DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tracy Gibson, AED.TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff does not provide adequate supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
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On 05/30/25 around 03:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unnanounced visit to deliver the above complaint finding. LPA met with Tracy Gibson, Assistant ED and explained the purpose of the visit.

During the invetigation, LPA toured the facility and interviewed Staff (S2, S3, S4, S5, S6), Witnessess (W1, W2, W3), reviewed and requested Staff and Resident roster, and the following documents from Resident's (R1, R2, R3, R4, R5, R6, R7) file: Physician's Report(s), Identification and Emergency Information, Appraisal Needs and Services Plan, any elopements for April-May, and LIC 500.


Allegation: SUBSTANTIATED
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20250506154801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EL CERRITO ROYALE
FACILITY NUMBER: 075600575
VISIT DATE: 05/30/2025
NARRATIVE
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...Continued from LIC9099.

Staff does not provide adequate supervision resulting in resident wandering away from facility.
LPA reviewed a sample of Residents records (R1, R2, R3). The LIC602 dated 02/25/25 for R1 revealed the R1 has macular degeneration, essential tremors, Mild Cognitive Impairment (MCI), and is unable to leave the facility unassisted. R1’s LIC 624 dated 05/20/25 reports that on 05/13/25 R1 left the facility without supervision and was returned to the facility by El Cerrito Police department. S6 stated that the staffing was questionable, and both Assisted Living and Memory Care's staffing should be assessed, and S7 stated that there should be more focus on the actual care of the residents.

Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted, appeal rights and a copy of this report provided Tracy Gibson, AED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250506154801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: EL CERRITO ROYALE
FACILITY NUMBER: 075600575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
87463(j)
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The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal.
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Licensee (LIC) to establish new admissions protocol to review resident records, LIC602, preappraisal needs and services to ensure sufficient trained staff are available for the care and services of all residents. LIC & staff to certify with signatures that the regulation has been reviewed by POC.
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-This requirement is not met as evidenced by:

Supervision was not present to prevent R1 from leaving the facility unassisted per R1's physician's report.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250506154801

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: 99DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Tracy Gibson, AED.TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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9
taff leaves resident soiled for an extended period of time.

Staff does not ensure to dispose expired medical care supplies.
INVESTIGATION FINDINGS:
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On 05/30/25 around 03:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unnanounced visit to deliver the above complaint finding. LPA met with Tracy Gibson, Assistant ED and explained the purpose of the visit.

During the invetigation, LPA toured the facility and interviewed Staff (S2, S3, S4, S5, S6), Witnessess (W1, W2, W3), reviewed and requested Staff and Resident roster, and the following documents from Resident's (R1, R2, R3, R4, R5, R6, R7) file: Physician's Report(s), Identification and Emergency Information, Appraisal Needs and Services Plan, any elopements for April-May, and LIC 500.


Allegation: UNSUBSTANTIATED
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250506154801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EL CERRITO ROYALE
FACILITY NUMBER: 075600575
VISIT DATE: 05/30/2025
NARRATIVE
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...continued from LIC9099A.

Allegation: UNSUBSTANTIATED
Staff leaves resident soiled for an extended period of time.
Staff does not ensure to dispose expired medical care supplies.

Staff leaves resident soiled for an extended period of time.
The allegation is related to R1 being soiled with feces for over 2 hours. Interviews with Staff S4, S5, S6 and S7 reveal that they were not aware R1 or any other resident remaining soiled for over 2 hours. S5 and S7 confirmed that a response to the resident could take up to 30 minutes after a caregiver is requested over the radio.

Staff does not ensure to dispose expired medical care supplies.
S8 stated that an expired medical supply was left unattended S1 at the facility. LPA and S2 toured the LPA toured the medical station, kitchen, shower and laundry room; there weren’t’ any expired medical supplies and the medication that were no longer in use were properly destroyed and remained lock with a destruction that was monitored and control by S3 on the day of the visit.

Based on information obtained, the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met.

Exit interview conducted, appeal rights and a copy of this report provided Tracy Gibson, AED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5