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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 09/16/2024
Date Signed: 09/16/2024 06:02:14 PM

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
09/11/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240911142042
FACILITY NAME:ELEGANCE BERKELEYFACILITY NUMBER:
019201143
ADMINISTRATOR:COE, ROBERTFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(510) 788-1333
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:120CENSUS: 49DATE:
09/16/2024
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Douglas Blake, Interim-Executive DirectorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent a resident from eloping.
Staff do not distribute residents' medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/16/2024 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegations. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit.

ALLEGATIONS:
Staff did not prevent a resident from eloping.
Staff do not distribute residents' medications as prescribed.
SUBSTANTIATED

Deficiencies were cited on a Case Management LIC809D and Complaint #15-AS-20240830161136 LIC
9099D on 09/11/24.

Exit interview conducted. A copy of this report and appeal rights were provided to ED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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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