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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 12/12/2024
Date Signed: 12/12/2024 06:09:54 PM

Document Has Been Signed on 12/12/2024 06:09 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: DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Mary Anne Watral, Interim-Executive Director (ED)TIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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On 12/12/2024 around 04:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an Unusual Incident Report received regarding Resident #1 (R1). LPA met with Mary Anne Watral, Operations Specialist (OS)

LPA interviewed OP and S2. LPA requested and reviewed R1's Physician's Report (LIC602), Functional Evaluation, Resident Appraisal needs and UIR dated 12/11/24. LPA confirmed that R1 can leave the facility unassisted. R1 was locked out of the facility, was able to contact his/her daughter from a passerby, and was returned to the facility on 12/04/24. As a result of R1's confusion, R1 to follow-up with the Primary Care Physician on 12/13/24. The facility has contracted an agency (RTF) to install a keyless entry pad along with a notification system at the front entrance.

LPA and OP discussed recent incidents with Residents (R1, R2, R3, R4); incident reports will follow. OP self reported that an internal investigation is underway for S1 and R4. All required parties have been notified of the incidents.

No deficiencies cited, exit interview conducted, and a copy of this report provided to OP.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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