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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 05/30/2024
Date Signed: 05/30/2024 05:48:04 PM


Document Has Been Signed on 05/30/2024 05:48 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: 94DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Sonja Givens, AdministratorTIME COMPLETED:
06:15 PM
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On 05/30/24 around 05:00 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.

On 05/30/2024 Licensing Program Analyst (LPA) L. Holmes received a report of suspected elder abuse from Witness #1 (W1). It was reported that on 05/27/2024 that Resident (R1) slapped (R2) across the face. After record reviews and interview with ED, the same incident was reported via an SOC 341 on 05/30/24. Staff (S1) observed R1 and R2 sitting next to each other. R2 has a history of false perceptions, and screaming. R2 perhaps became annoyed and then made contact with R2's left side of the face from R1's palm. R2 has a history of neuro-cognitive disorder and does not remember the chain of events. R1 and R2 are spouses; therefore, the facility has initiated to supervise R1 and R2 so that they can enjoy their meals throughout the day and redirect when necessary.

Exit interview conducted and a copy of this report provided to ED.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 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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