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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 11/20/2024
Date Signed: 11/20/2024 01:01:28 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
08/15/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240815084759
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: 47DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Interim-Executive Director (ED)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure residents room was kept safe, clean, and sanitary
Staff did not ensure residents personal belongings were safely secured
Staff did not ensure residents records were properly maintained
Staff did not ensure residents medications were properly managed
Staff did not ensure residents medications were dispensed as prescribed

INVESTIGATION FINDINGS:
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On 11/20/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Mary Anne Watral, Operations Specialist (OP) and Interim-Douglas Blake, Executive Director (ED) and explained the purpose of the visit.

During the course of the investigation and visit, LPA toured the facility conducted interviews with ED, OP, Staff, and Witness #1. LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), Resident Roster, copies of R1's Centrally Stored Medication Log, medication records, housekeeping schedule, blood sugar record, LIC602, and Admission Agreement.

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

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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 9
Control Number 15-AS-20240815084759
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: 11/20/2024
NARRATIVE
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...continued from LIC9099.

Allegations: SUBSTANTIATED
Staff did not ensure residents room was kept safe, clean, and sanitary
Staff did not ensure residents personal belongings were safely secured
Staff did not ensure residents records were properly maintained
Staff did not ensure residents medications were properly managed
Staff did not ensure residents medications were dispensed as prescribed

Staff did not ensure residents room was kept safe, clean, and sanitary.
W1 reported during a visit the weekend of May 17, 2024, R1's room was found with the waste basket overflowing with used depends, clothes and papers strewn over the bed, the room hadn't been vacuumed, laundry was undone, the bedding hadn’t been changed, and there was mold growing on R1’s plates that were left in the kitchen sink and open containers of food on the counter tops. S2 stated that it should not had mattered if cleaning is the job of housekeeping, R1’s room was untidy and R1 needed to be relocated for cleaning March 2024. S12 reported that the staff keep reporting things to S1 and nothing was being done, therefore the allegation is substantiated.

Staff did not ensure residents personal belongings were safely secured.
The above allegation refers to the facility not having an adequate policy in place to track residents’ laundry to prevent frequent losses of R1’s clothing which were either never returned or mistakenly worn by other residents according to W1. W1 and S2 stated that on that day of R1’s move-out, the caregivers on duty did not know which laundered items belonged to R1. The items are supposed to be labeled but normally are not, therefore the allegation is substantiated.

Staff did not ensure residents records were properly maintained.
R1 is diabetic and R1’s Functional Evaluation states that the MedTech is to cue R1 to perform a Finger Stick Blood Glucose (FSBG) test twice daily and there’s not any record of performance or denials of FSBG. The document created by S3 to capture R1’s blood sugar, only recorded the dates from 06/24/2024 to 07/23/24 out of the entire time of R1’s residential agreement from 11/22/23 to 08/10/24 therefore the allegation is substantiated.
Continued on 9099C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 15-AS-20240815084759
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: 11/20/2024
NARRATIVE
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...continued from 9099C.

Staff did not ensure residents medications were properly managed.
Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there are not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7; the document captured the dates of 06/24/2024 to 07/23/24 during R1’s residential agreement from 11/22/23 to 08/10/24 and there are no other documents for R1, therefore the allegation is substantiated.

Staff did not ensure residents medications were dispensed as prescribed.
Per W1, S1 stated that R1’s critical medical documents were faxed to an unsecured public area. LPA, LPM and S7 toured the facility and there were not any facsimiles that were accessible to the public. S1 is no longer employed at the facility; however, LPA was able to review R1’s records and confirmed that a document for R1’s blood sugar was created by S3 per W1, S2, and S7. S3 provided the electronic Centrally Stored Medication and Destruction Records for March 2024; when compared with the Medication Sheet for March 2024 it is inconsistent for the medication (Metformin) being dispensed or refused on the following dates of 03/19 - 03/25/2024 and 03/27 - 03/31/2024 therefore the allegation is substantiated.


Continued on 9099C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 15-AS-20240815084759
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: 11/20/2024
NARRATIVE
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...continued from 9099C.

A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $250 is hereby assessed for a repeat violation times two (2).

Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
08/15/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240815084759

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: 47DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Interim-Executive Director (ED) TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident received adequate laundry services
Staff did not ensure resident received personal mail parcels
Staff did not ensure residents dietary care plan was properly followed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/20/2024 around 09:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the above allegations. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit.

During the course of the investigation and visit, LPA toured the facility conducted interviews with ED, OP, Staff and Witness #1. LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), Resident Roster, copies of R1's Centrally Stored Medication Log, medication records, housekeeping schedule, blood sugar record, LIC602, and Admission Agreement.

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

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 15-AS-20240815084759
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: 11/20/2024
NARRATIVE
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...continued from 9099.

Staff did not ensure resident received adequate laundry services.
W1 presented photos of R1’s room the weekend of May 17, 2024, and none of the photo’s presented not laundered clothing or bedding. S12 presented photos of R1’s room on March 2, 2024, and none of the photo’s presented not laundered clothing or bedding. Although the bedding had clothes and paper strewn on top, LPA could not confirm or deny if the clothes or bedding were not laundered. After interviewing S2, S12 and W1. Interviews revealed the primary complaint was R1’s kitchen being uncleaned, therefore the allegation is unsubstantiated.

Staff did not ensure resident received personal mail parcels.
LPA observed S13 sorting mail. LPA had a conversation with S13 about trying to catch-up on all the different mail that came in over the weekend. W1 stated that R1's Google camera was missing and never delivered to R1 and provided a tracking number. LPA requested proof of delivery to the facility from W1. S1 is no longer employed for an interview regarding investigation of the missing parcel. After file review, LPA did not observe any complaints or a history of missing parcels, therefore the allegation is unsubstantiated.

Staff did not ensure residents dietary care plan was properly followed.


LPA toured the facility and observed a white board and dietary binder that listed the names and conditions of residents with dietary restrictions. S10 was aware that R1 was diabetic, and confirmed that S1, S10 and the kitchen staff met monthly to determine if meals needed to be modified or changed. S10 confirmed that the staff could not deny residents food but would steer them from carbohydrates, therefore 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 deficiencies cited.

    Exit interview conducted, Appeal Rights, and a copy of this report provided to ED.

    SUPERVISORS NAME: Yvonne Flores-Larios
    LICENSING EVALUATOR NAME: Lisha Holmes
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 11/20/2024
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 11/20/2024
    LIC9099 (FAS) - (06/04)
    Page: 4 of 9
    Control Number 15-AS-20240815084759
    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
    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 11/20/2024
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type B
    12/03/2024
    Section Cited
    CCR
    87303(d)(2)
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    		87303 Maintenance and Operation (d) The following space and safety provisions shall apply to all facilities:
    (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
    -This requirement is not met as evidenced by:
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    		Executive Director to provide training by a third-party vendor and submit copy of training topic(s) with attendees signatures by 12/03/24
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    		Based on interviews and records reviewed, the licensee did not comply with the section above by not properly maintaining R1’s bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
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    Type B
    12/03/2024
    Section Cited
    CCR
    87217(b)
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    		87217 Safeguards for Resident Cash, Personal Property, and Valuables
    (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.....
    -This requirement is not met as evidenced by:
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    		Executive Director to provide in service training and submit a copy of training topic(s) with attendees signatures by 12/03/24
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    		Based on interviews, the licensee did not comply with the section above by not safeguarding R1's clothing items which poses/posed a potential 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.
    SUPERVISORS NAME: Yvonne Flores-Larios
    LICENSING EVALUATOR NAME: Lisha Holmes
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 11/20/2024
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 11/20/2024
    LIC9099 (FAS) - (06/04)
    Page: 6 of 9
    Control Number 15-AS-20240815084759
    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
    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 11/20/2024
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type B
    12/03/2024
    Section Cited
    CCR
    87506(b)(11)
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    		87506 Resident Records (b) Each resident’s record shall contain at least the following information: (11) The documentation required by Section 87611 for residents with an allowable health condition.-This requirement is not met as evidenced by:
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    		Executive Director to provide training by a third-party vendor and submit a copy of training topic(s) with attendees signatures by 12/03/24
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    		Based on interviews, the licensee did not comply with the section above by not safeguarding R1's clothing items which poses/posed a potential health, safety or personal rights risk to persons in care.
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    Type B
    12/03/2024
    Section Cited
    CCR
    87465(a)(4)
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    		87465 Incidental Medical and Dental Care (a) A plan...shall be developed by each facility... encourage routine medical and dental care and provide for assistance...by compliance with...(4) The licensee shall assist residents with self-administered medications as needed,
    -This requirement is not met as evidenced by:
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    		Executive Director to provide training by a third-party vendor for all staff that administer medication and submit a copy of training topic(s) with attendees signatures by 12/03/24.
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    		Based on interviews and records reviewed, Licensee did not ensure R1's blood sugar and/or medications were documented which poses/posed a potential 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.
    SUPERVISORS NAME: Yvonne Flores-Larios
    LICENSING EVALUATOR NAME: Lisha Holmes
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 11/20/2024
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 11/20/2024
    LIC9099 (FAS) - (06/04)
    Page: 7 of 9
    Control Number 15-AS-20240815084759
    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
    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 11/20/2024
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type A
    11/21/2024
    Section Cited
    CCR
    87628(b)(2)
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    		87628 Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible...(2) Ensuring that sufficient amounts of medicines, testing equipment...other supplies...as specified in Section 87465(c)..-This requirement is not met as evidenced by:
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    		Executive Director to provide training by a third-party vendor on or before for all staff that administer medication and submit a copy of training topic(s) with attendees signatures by 11/21/24 for in-service training.
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    		Based on interviews and records reviewed, the licensee did not comply with the section above by not testing R1's blood sugar and dispensing R1's medication as prescribed which poses/posed 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.
    SUPERVISORS NAME: Yvonne Flores-Larios
    LICENSING EVALUATOR NAME: Lisha Holmes
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 11/20/2024
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 11/20/2024
    LIC9099 (FAS) - (06/04)
    Page: 2 of 9