075600575-5-30-2024-15-AS-LHOS-D5S2X3-20240530174627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 05/30/2024
Date Signed: 05/30/2024 05:47:16 PM

Document Has Been Signed on 05/30/2024 05:47 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 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: 92	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sonja, Givens, Executive Director (ED)		TIME COMPLETED:	06:15 PM

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On 05/30/24 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Sonja Givens, Executive Director (ED) and Tracy Gibson, Assistant ED and explained the purpose of the visit. ED currently holds standard certificate (#6002048740) exp. 02/03/2025. The facility’s fire clearance was approved for sixty (60) non-ambulatory residents; twenty (20) may have hospice waivers.

Upon arrival, LPA observed five (5) residents lounging, conversing and putting a puzzle together. Several staff and residents were in the dining area. Staff and residents were moving about throughout the facility's common areas. LPA toured the facility including, but not limited to the common areas, bathroom, dining area, and front courtyard. The facility consists of individual apartments and a memory care unit. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at the facility. The facility has an emergency food supply on site and contract with Sysco Foods, Rubino Produce and Weber Meats along with other vendors for weekly deliveries. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was 107 degrees Fahrenheit (F) with hand washing soap, signs, and paper towels; the areas were safe, and sanitary. Linen and hygiene products are available for all residents. PPE, sanitizer, and paper goods remain sufficient.

Continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/30/2024

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...continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 02/11/24. Emergency Disaster Plan is updated, disaster drill last conducted March 2024 and an elopement drill on 05/23/24.

Five (5) staff and Nine (9) residents records were reviewed and are complete.

The following forms are to be updated and submitted to CCLD:
-Resident Roster (Reviewed)
-LIC500 Personnel Report (Reviewed)
-LIC308 Update Designation of Administrative Responsibility
-LIC610D Emergency Disaster Plan (Reviewed)

Exit interview conducted and a copy of this report provided to ED.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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