Inspection Reports for El Cerrito Royale
6510 Gladys Ave, El Cerrito, CA 94530, CA, 94530
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, reflecting a generally clean and well-maintained facility with proper safety measures and infection control practices. Several complaint investigations were unsubstantiated, including allegations about visitation restrictions and supervision concerns. However, two complaint investigations were substantiated: one in January 2025 found the facility issued an unlawful eviction notice lacking required details, and another in May 2025 identified inadequate staff supervision that allowed a resident to leave unassisted. The most recent report from May 30, 2025, included this deficiency related to staffing but otherwise noted the facility was clean and safe. There is no clear pattern of worsening or improving conditions, though the facility has addressed safety and supervision issues as they arose.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 99
Capacity: 145
Deficiencies: 0
May 30, 2025
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and ensure the health and safety of residents.
Findings
The facility was observed to be clean, safe, and well-maintained with adequate lighting, emergency food supply, and proper hot water temperature. Smoke detectors, carbon monoxide detectors, and fire extinguishers were in working order. Several forms were reviewed and found complete, though some forms require updating and submission to the licensing agency.
Report Facts
Staff records reviewed: 5
Resident records reviewed: 7
Fire extinguisher inspection date: Feb 7, 2025
Fire clearance capacity: 60
Hospice waivers allowed: 20
Hot water temperature: 108
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and signed the report |
| Tracy Gibson | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Sonja Givens | Administrator/Director | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 1
May 30, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2025-05-06 regarding inadequate supervision resulting in resident wandering and other care concerns.
Findings
The investigation substantiated that staff did not provide adequate supervision, resulting in a resident leaving the facility unassisted. Another allegation regarding residents being left soiled and expired medical supplies was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for inadequate supervision leading to resident wandering away from the facility. The allegation regarding staff leaving residents soiled and failure to dispose expired medical supplies was unsubstantiated.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to ensure sufficient direct care staff to support residents' needs, evidenced by lack of supervision preventing a resident from leaving the facility unassisted. | Type A |
Report Facts
Capacity: 145
Census: 99
Deficiencies cited: 1
Plan of Correction Due Date: Jun 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Oversaw the complaint investigation |
| Tracy Gibson | Assistant Executive Director | Facility representative met during investigation and exit interview |
| Sonja Givens | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 145
Deficiencies: 1
Jan 15, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that staff unlawfully evicted a resident.
Findings
The investigation substantiated the allegation that staff unlawfully evicted a resident by providing a sixty-day written notice to quit that did not specify the date, place, witnesses, and circumstances concerning the reasons for eviction.
Complaint Details
The complaint was substantiated. The allegation was that staff unlawfully evicted a resident. Evidence showed the notice to quit lacked required details. The deficiency was cited under Title 22 California Code of Regulations 87224(d).
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. | Type B |
Report Facts
Capacity: 145
Census: 94
Deficiency Type: 1
Plan of Correction Due Date: Jan 17, 2025
Notice Days: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 145
Deficiencies: 0
May 31, 2024
Visit Reason
An unannounced 10-day complaint investigation visit was conducted to investigate an allegation of lack of supervision by staff following a report of suspected elder abuse involving two residents.
Findings
The investigation found that although the incident of one resident slapping another may have occurred, there was insufficient evidence to substantiate the allegation of lack of supervision by staff. Staffing was sufficient at the time, and both involved residents were regularly supervised with trained staff present.
Complaint Details
The complaint involved an allegation of lack of supervision by staff after Resident 1 slapped Resident 2. The allegation was unsubstantiated due to lack of preponderance of evidence despite the incident possibly occurring.
Report Facts
Complaint control number: 15
Complaint control number suffix: 20240530153125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Tracy Gibson | Assistant ED | Met with Licensing Program Analyst during the visit and received the exit interview |
Inspection Report
Annual Inspection
Census: 92
Capacity: 145
Deficiencies: 0
May 30, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and facility standards.
Findings
The facility was found to be generally compliant with safety and sanitation standards, including adequate lighting, safe hot water temperature, unobstructed passageways, and operational smoke detectors and carbon monoxide alarms. Some administrative forms require updating and submission to the licensing authority.
Report Facts
Residents observed lounging: 5
Staff records reviewed: 5
Resident records reviewed: 9
Fire clearance capacity: 60
Hospice waivers allowed: 20
Hot water temperature: 107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Executive Director | Met with Licensing Program Analyst during inspection |
| Tracy Gibson | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection and signed the report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 94
Capacity: 145
Deficiencies: 0
May 30, 2024
Visit Reason
An unannounced annual inspection was conducted by Licensing Program Analyst L. Holmes to evaluate the facility's compliance and investigate a reported incident of suspected elder abuse.
Findings
The inspection included review of a reported incident where one resident slapped another. The facility documented the incident, initiated supervision of the involved residents, and took steps to ensure their safety and well-being during meals.
Complaint Details
The visit was triggered by a report of suspected elder abuse involving two residents, one slapping the other. The incident was substantiated through record review and interviews, and the facility responded by increasing supervision.
Report Facts
Fire clearance non-ambulatory residents: 60
Hospice waivers: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Administrator / Executive Director | Met with Licensing Program Analyst during inspection and interviewed regarding incident |
| Tracy Gibson | Assistant Executive Director | Met with Licensing Program Analyst during inspection |
| L. Holmes | Licensing Program Analyst | Conducted the inspection and received the elder abuse report |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 103
Capacity: 145
Deficiencies: 0
May 30, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and facility operations.
Findings
The facility was found to be in compliance with safety, sanitation, and operational standards. Fire clearance was approved for 60 non-ambulatory residents with hospice waivers. Staff and resident records were complete, and emergency plans were updated. Some forms require updating and submission to the licensing division.
Report Facts
Fire clearance capacity: 60
Hospice waivers allowed: 15
Hot water temperature range: 108
Hot water temperature range: 110
Staff records reviewed: 5
Resident records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Administrator | Met with Licensing Program Analysts during inspection |
| Tracy Gibson | Executive Director | Met with Licensing Program Analysts during inspection |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection |
| Kelly Nguyen | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 145
Deficiencies: 0
Jan 20, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that a resident eloped without staff knowledge and that staff did not allow a family member to visit the resident.
Findings
The investigation found the allegations to be unsubstantiated. The resident did elope but was found and returned within an hour, and visitation restrictions were based on physician orders due to the resident's medical condition.
Complaint Details
The complaint involved allegations that a resident eloped without staff knowledge and that staff did not allow a family member to visit the resident. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.
Report Facts
Facility capacity: 145
Resident census: 99
Complaint receipt date: Sep 29, 2022
Inspection visit time: 1115
Inspection completion time: 1200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation visit |
| Sonja Givens | Administrator | Facility administrator met during inspection |
| Tracy Gibson | Assistant Executive Director | Met with Licensing Program Analyst during visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 92
Capacity: 145
Deficiencies: 0
Aug 22, 2022
Visit Reason
An unannounced case management visit was conducted pertaining to Resident #1 who eloped on 08/11/2022.
Findings
The resident eloped from the facility but was found about three blocks away by the police and returned after about an hour. No deficiencies were cited during this visit. Additional staff training and research for installation of additional egresses were planned.
Report Facts
Capacity: 145
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Gibson | Assistant Executive Director | Met during the visit and participated in the exit interview |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection visit |
| Meenakshi Malik | Licensing Program Analyst | Conducted the inspection visit |
Inspection Report
Routine
Census: 96
Capacity: 145
Deficiencies: 0
May 5, 2022
Visit Reason
An unannounced Infection Control Inspection was conducted as part of the required 1-year visit to assess the facility's compliance with infection control and COVID-19 mitigation protocols.
Findings
The facility has a COVID-19 mitigation plan on file, adequate supplies of food and PPE, operational safety equipment, and proper infection control signage and screening stations. Several forms were noted to be updated and submitted by 05/12/2022.
Report Facts
Hot water temperature: 106.4
Common area temperature: 73
Facility capacity: 145
Facility census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Administrator | Met during inspection and discussed staffing plans |
| Tracy Gibson | Assistant Executive Director | Met during inspection and discussed staffing plans |
| Lisha Holmes | Licensing Program Analyst | Conducted the inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 145
Deficiencies: 0
Mar 11, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility was not following current visitor guidelines.
Findings
The investigation found no discrepancies in records or interviews. The facility was allowing visitation according to current guidelines, with proper signage, waivers, and verification procedures. The allegations were unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility was not following current visitor guidelines. After investigation, the allegations were found to be unsubstantiated.
Report Facts
Capacity: 145
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sonja Givens | Administrator | Met with Licensing Program Analyst during investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Routine
Census: 99
Capacity: 145
Deficiencies: 0
Jul 16, 2021
Visit Reason
The inspection was an unannounced Infection Control Inspection conducted as a required one-year visit.
Findings
The Licensing Program Analyst observed proper infection control measures including PPE availability, screening stations, and handwashing facilities. No deficiencies were cited during the inspection.
Report Facts
Capacity: 145
Census: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kisha Harris | Social Services Director | Met with Licensing Program Analyst during inspection |
| Laura Hall | Licensing Program Analyst | Conducted the Infection Control Inspection |
| Harpreet Humpal | Licensing Program Manager | Named in report header |
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