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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:47:04 PM

Document Has Been Signed on 10/24/2024 02:47 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:ELEGANCE BERKELEYFACILITY NUMBER:
019201143
ADMINISTRATOR/
DIRECTOR:		COE, ROBERTFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(510) 788-1333
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 120CENSUS: 49DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Douglas Blake, Executive Director TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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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, open a complaint and completed a case management regarding Resident #1 (R1). 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 an interview with ED and confirmed that R1's reappraisal was due on 09/10/24 as a result of a case management on 09/03/24. A Functional Evaluation was not completed until 10/02/24.

Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, a copy of this report, and appeal rights provided to 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
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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Document Has Been Signed on 10/24/2024 02:47 PM - It Cannot Be Edited


Created By: Lisha Holmes On 10/24/2024 at 01:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2024
Section Cited
HSC
87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who...retain residents with dementia shall be...ensuring the following:(5) ...annual medical assessment...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. -This requirement is not met as evidenced by
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ED to reappraisal R1 on or before 10/29/2024; LIC 625 (10/24) – Appraisal/Needs and Services Plan and rpovide CCLD a plan for R1 to store and safeguard medications.
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by R1 not having reappraisal by the POC which poses an immediate health, safety, or personal rights risk to persons in 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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