075600575-7-10-2024-15-AS-YFLS-D72VU2-20240710164358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600575
Report Date: 05/31/2024
Date Signed: 07/10/2024 01:01:18 PM

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
05/30/2024 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240530153125

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:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Tracy Gibson, Assistant ED		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Lack of supervision by staff.

INVESTIGATION FINDINGS:

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On 07/10/24 around 12:50 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to amend the report to 'Public'.

On 05/31/24 around 03:45 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced 10-day complaint visit to investigate and deliver the finding. LPA met with Tracy Gibson, Assistant ED and explained the purpose of the visit.

Allegation:
Lack of supervision by staff.

For the allegation lack of supervision by staff, on 05/30/2024 Licensing Program Analyst (LPA) L. Holmes received a report of suspected elder abuse from Witness #1 (W1) and completed a case management. It was reported that on 05/27/2024 Resident (R1) slapped (R2) across the face. After record reviews of LIC500, Physician Reports and interview with ED, along with the same incident that was self-reported via an SOC 341 on 05/30/24 by Staff (S1), S1 observed R1 and R2 sitting next to each other in the Memory Care Unit (MC). Continued on 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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20240530153125

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: 05/31/2024

NARRATIVE

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...continued from LIC9099.

R2 has a history of false perceptions and screaming; R2 was engaging in impromptu screaming on that day, R1 perhaps became annoyed and then made contact with R2's left side of the face with R1's palm. R1’s Physician Report dated 11/17/23 revealed that R1 has a history of neuro-cognitive disorder along with confusion, disorientation, and does not remember the chain of events. R2’s Physician Report dated 04/22/24 revealed that R2 is diagnosed with Dementia. R1 and R2 are spouses and are regularly supervised; therefore, the facility initiated to supervise R1 and R2 when they are together so that they can enjoy their meals throughout the day and redirect when necessary. Staffing was sufficient at that time, S1 and S2 were both present, and both have certified training in “Understanding Dementia”.

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

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

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