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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600577
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:20:16 AM

Substantiated


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
04/05/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230405081820
FACILITY NAME:MORAGA ROYALEFACILITY NUMBER:
075600577
ADMINISTRATOR:RICKMAN, FAILELOTO TFACILITY TYPE:
740
ADDRESS:1600 CANYON ROADTELEPHONE:
(925) 376-8900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:120CENSUS: DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Loto Rickman, TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff does not allow residents to leave room due to barrier in front of resident's bedroom door
INVESTIGATION FINDINGS:
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On 04/06/2023 starting at 09:05 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Executive Director, Loto Rickman and explained the purpose of the visit.

During the course of investigation, LPA obtained information and interviewed 5 staff. LPA toured the facility and observed 7 rooms in memory care that have velvet cords or rings on the wall to connect the velvet cords. Based on interview with staff, it was revealed that there are cords Infront of some of the rooms in memory care. Staff stated that these cords are only used at nighttime to prevent the residents from wondering around.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230405081820
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: MORAGA ROYALE
FACILITY NUMBER: 075600577
VISIT DATE: 04/06/2023
NARRATIVE
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...Continued from 9099


Based on LPA’s interviews and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20230405081820
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: MORAGA ROYALE
FACILITY NUMBER: 075600577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/20/2023
Section Cited
CCR
87468.1(a)(6)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... This requirement was not met as evidenced by:
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The facility agrees to remove the ropes and hook rings from the doors. Proof Of Correction (POC) will be sent to CCLD by POC date.
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LPA observed the rooms having Velvet hanging stanchion ropes on the outside of doors in memory care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3