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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:41:28 PM

Unsubstantiated


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
10/15/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241015162638
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:
10/24/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Douglas Blake, Interim-Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not provide resident's medication as prescribed
Staff did not monitor resident's blood pressure to ensure it was safe for resident to take medication
Staff are billing resident for services not being rendered
Staff are not adequately trained to meet resident needs
INVESTIGATION FINDINGS:
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On 10/24/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a needs further investigation for the above allegations. LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit.

During the course of the investigation and visit, LPA conducted interviews with ED, Resident #1 (R1). LPA requested R1’s current medication list, billing statement and the following documents were reviewed from previous complaint #15-AS-20240830161138 on 08/30/24: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 2
Control Number 15-AS-20241015162638
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: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 10/24/2024
NARRATIVE
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...continued from LIC9099.

Allegations: UNSUBSTANTIATED
Staff did not provide resident's medication as prescribed
Staff did not monitor resident's blood pressure to ensure it was safe for resident to take medication
Staff are not adequately trained to meet resident needs

LPA interviewed R1, and R1 stated that he/she was concerned that S1 hadn't been fired. S1 never apologized for doing anything wrong and is still passing medications. On 09/09/24, R1 received a doctor's order to administer his/her own medication, and S2 performed a Medication Self Administration evaluation on 10/02/24 after R1 presented S2 with the physician's note. The license was cited on complaint 15-AS-20240830161136 received 08/30/24 and provided proof of corrections for the above allegations.

Allegation: UNSUBSTANTIATED
Staff are billing resident for services not being rendered.

ED stated that he/she was unaware of a billing issue or dispute related to R1. ED had not received any written or oral communications from R1 regarding billing. ED provided LPA with proof of R1's transaction history for 10/2024 that shows a credit for services, and explained it was effective 10/02/2024 when S2 performed a Medication Self Administration evaluation for R1. ED will provide an explanation and notification to R1 on or before 11/04/2024.

Based on information obtained, the allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met.

No deficiency cited, exit interview conducted, a copy of this report and appeal rights provided to Douglas Blake, ED.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2