075600575-5-30-2023-15-AS-LHOS-CSBRA9-20230530125047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600575
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:50:58 PM

Document Has Been Signed on 05/30/2023 12:50 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: 103	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Sonja Givens, Administrator		TIME COMPLETED:	01:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/30/23 at 09:30 PM, Licensing Program Analysts (LPAs) L. Holmes and Kelly Nguyen conducted an unannounced annual inspection. LPAs met with Sonja Givens, Administrator (ADM) and Tracy Gibson, Executive (ED) and explained the purpose of the visit. ADM currently holds standard certificate (6002048740). The facility’s fire clearance was approved for sixty (60) non-ambulatory residents; fifteen (15) may have hospice waivers. Upon arrival LPA observed one (1) resident dining, four (4) staff monitoring the facility and attending to residents in the common area. LPA K. Nguyen and ADM toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, 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. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods; there is also an emergency food supply on site and Sysco food delivers weekly. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in a sample of five (5) residents' apartments measured at 108-110 degrees (F). All bathrooms, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed throughout washing stations. 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: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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: 05/30/2023

NARRATIVE

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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 12/13/22. Emergency Disaster Plan is updated and disaster drill last conducted 02/17/23.

Five (5) staff records were reviewed, and all staff have criminal record clearances. Five (5) 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 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-Administrator Certificate

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

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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