075600575-1-20-2023-15-AS-YFLS-CNLVT7-20230131154238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600575
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:48:51 AM

Unsubstantiated

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
09/29/2022 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220929083018

FACILITY NAME:	EL CERRITO ROYALE		FACILITY NUMBER:	075600575
ADMINISTRATOR:	GIVENS, SONJA		FACILITY TYPE:	740
ADDRESS:	6510 GLADYS AVENUE		TELEPHONE:	(510) 234-5200
CITY:	EL CERRITO	STATE: CA	ZIP CODE:	94530
CAPACITY:	145	CENSUS: 99	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Sonja Givens, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident eloped without staff knowledge

Staff did not allow family member to visit resident

INVESTIGATION FINDINGS:

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On 01/20/23 at 11:15 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver the complaint findings for the above allegations. LPA explained the purpose of the visit with Tracy Gibson, Assistant Executive Director

Allegations:
Resident eloped without staff knowledge
Staff did not allow family member to visit resident
Investigation Finding: UNSUBSTANTIATED

On 08/11/22 prior to the elopement, LPA, S1 and S2 had a phone appointment and discussed the change in conditions, reappraisal, needs and services plan and 60-day eviction for R1. R1 entered a respite agreement for a 30 day stay effective 05/10/2022.
Continued in LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220929083018

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: 01/20/2023

NARRATIVE

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…. continued from LIC9099
R1 did not have a history of elopement or exit-seeking behavior at the facility, and wore 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 called immediately. S2 also drove around the community in search of R1. R1 was found about 3 blocks away by the El Cerrito Police Department and was returned within an hour of the elopement.

R1’s Physician Report dated 06/06/2022 stated that R1 has late onset Alzheimer’s disease with behavioral disturbance. R1 displayed biting, combative, disruptive, and agitated behaviors, difficulty recognizing family members; therefore, ceasing visitation and outside food for 30 days was recommended by R1’s physician. Once R1 was settled in the facility, family visits would resume. Visitor logs dated 08/11 & 08/18 documents visits from RP. Interviews with S1, S2 and W1 revealed that there was visitation prior to the physician’s orders. R1’s respite agreement expired 06/10/22. R1 was relocated to another Community Care Licensing Facility with the assistance of S1 around 08/20/22.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided to Sonja Givens, Administrator

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC9099 (FAS) - (06/04)

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