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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:24:15 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
09/17/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917163033
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: 48DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Douglas Blake, Interim Executive Director (ED) and Incoming Executive Director, Annemarie Domizio TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left residents in soiled diapers for an extended period of time resulting in injury
Staff sleeping during work hours
Staff screamed at resident
INVESTIGATION FINDINGS:
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3
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5
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7
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9
10
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13
On 1/14/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Yvonne Flores-Larios arrived unannounced to deliver the findings for the above allegations. LPA and LPM met with Douglas Blake, Interim Executive Director (ED) and Executive Director (ED) Annemarie Domizio and explained the purpose for the visit.

During the course of the investigation and visits, LPA and LPM requested an updated staff and resident roster, reviewed staff schedules and training records, and requested documentation for Staff #7 (S7's). Personnel job descriptions & specifications, and contact information for staff. LPA and LPM requested residents' (R1, R2, R3, R4, R5) LIC602's, ID/Emergency Contact Information, Progress Notes and Centrally Store Medication and Destruction Reports. LPA and LPM interviewed staff (ED, S1, S2, S3, S4, S5, S16, S17, S18) and Witnesses (W2, W3, W4).

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 7
Control Number 15-AS-20240917163033
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: 01/14/2025
NARRATIVE
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5
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7
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9
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19
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32
...continued from 9099.

Staff left residents in soiled diapers for an extended period of time resulting in injury

S17 reported he/she has often arrived for his/her shift to find residents were left wet, dirty, full of feces, and with red bottoms, specifically R6 and their family members were complaining directly to S17. S2 stated he/she has been the only one on his/her PM shift showering residents and has complained to S5. S2 has sometimes witnessed unkept faces, clothes, bedding, and soiled sheets because the AM shift hadn't changed the linen, redness in private areas from being soiled, and resident wounds in memory care. S3 stated that he/she is a Med. Tech. and have found residents on the couch with their entire bottom wet, or dried feces, and redness on their private areas. LPA interviewed W2, W2 stated there's been multiple times where R3's briefs and pants have been wet. On 01/03/24, W2 emailed ED and S8 requesting toileting every three (3) to four (4) hours for R3. W2 discovered there was urine on R3’s depends, pants, and wheelchair seat during a music session and that those discoveries were happening too often and was unacceptable. W3 states that R5 wreaks of urine. W3 changed R5’s soiled wheelchair cushion but was still unsure if the smell was coming from R5’s catheter or colostomy bag. W4 stated that R1’s sheets were soiled on a past occasions; therefore, W4 purchased additional sheets. The facility allowed R5 to leave the facility with another family and there was a hygiene issue. W4 didn't elaborate but was quite upset about the occurrence and it was concerning. W4 thought the incident was a form of neglect. W4 stated that if R1 was in his/her right mind, being constantly clean would be very important for R1.

Continued on LIC9099C...

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

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20240917163033
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: 01/14/2025
NARRATIVE
1
2
3
4
5
6
7
8
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...continued from LIC9099C

Staff sleeping during work hours
ED stated that S7 may have been sleeping on the second floor during his/her 15-minute break and that S7 has a medical condition. S17 and S18 reported they’ve both seen S7 sleeping when S7 should have been working, and that their co-workers may also be calling to make complaints. LPA and LPM interviewed S18 and he/she stated that a resident was walking by and S7 was snoring, and S18 reported the incident to ED and S5. Although S2 never saw S7 sleeping, S2 stated residents don't want S7 on their assignments and when S7 is working, he/she is also on the phone or watching television in the common areas. LPA reviewed S7's file and did not find any approved accommodations from the facility.

Staff screamed at resident
S2 said that there was screaming on the second floor coming from S15 who was not treating the residents on the floor with respect. S5 said that there’s no policies about the residents. S18 stated that he/she did not like the way S9 was talking to R2. S18 said that R2 is slow to respond sometimes and maybe the staff needs to be training on how to deal with residents. S18 further stated that another staff, S19, was screaming at a resident R2 on 09/17/24 at 11:30am. S18 stated that resident was refusing to go downstairs to the dining room and S19 started screaming, “You need to go now.”


Based on LPA and LPM observations, interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. 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, appeal rights and a copy of this report provided to interim ED.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
09/17/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240917163033

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: 48DATE:
01/14/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Douglas Blake, Interim Executive Director (IED) and Executive Director (ED) Annemarie DomizioTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are eating residents food
Staff is not allowing resident to watch TV

INVESTIGATION FINDINGS:
1
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3
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5
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7
8
9
10
11
12
13
On 1/14/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Yvonne Flores-Larios arrived unannounced to deliver the findings for the above allegations. LPA and LPM met with Douglas Blake, Interim Executive Director (IED) and Executive Director (ED) Annemarie Domizio and explained the purpose for the visit.

During the course of the investigation and visits, LPA and LPM requested an updated staff and resident roster, reviewed staff schdeules and training records, and requested staff record for S7. Personnel job descriptions, job specifications, and contact information for staff. LPA and LPM requested residents' (R1, R2, R3, R4, R5) LIC602's, ID/Emergency Contact Information, Progress Notes and Centrally Store Medication and Destruction Reports. LPA and LPM interviewed staff (ED, S1, S2, S3, S4, S5, S16, S17, S18) and Witnesses (W2, W3, W4).

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20240917163033
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: 01/14/2025
NARRATIVE
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3
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...continued from LIC9099A.

Staff are eating residents food
S17 alleged that S7 was eating R6’s food. ED and S16 were not aware of the allegation. LPA and LPM interviewed S1. S1 stated that he/she helps residents with lunch and dinner. S2 stated they’ve never seen anyone eating any residents’ food. LPA interviewed Witnesses; W2 stated that he/she didn’t have any other concerns about abuse or the staff's skill level or appropriate treatment. W3 stated it's hard to find someone at the facility sometimes and W3 hasn’t seen anything, W4 feels that the care staff are lovely.

Staff is not allowing resident to watch TV
S18 alleged that S7 puts the television (TV) on, and watches what S7 wants to watch and not what the residents want to watch. The facility has individual apartments and communal areas with televisions. LPA toured the facility, including the second floor on 09/24/24, 10/24/24 and 12/23/24. Multiple residents were not watching TV; instead, they were primarily engaged in other activities facilitated by the care staff. The second floor is memory care (MC). Residents that are able to communicate, can retreat to their individual apartments or sit in the lounge area where the television is located.

A finding that the complaints are UNSUBSTANTIATED mean that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20240917163033
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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
CCR
87411(a)
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Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
-This requirement is not met as evidenced by:
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Licensee and administrator (ADM) to review all residents appraisals and care plans to ensure there is sufficient number of staff to provide adequate care and supervision to all residents. ADM to provide R2, R3, R4, R5 and their responsible parties a current incontinence care plan.
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Based on interviews and records reviewed, the licensee and ADM did not comply with the section above by not having sufficient and competent number of staff to meet R1, R2, R3, and R5’s incontinence care needs.
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ADM to provide to CCLD a current updated schedule for each shift by POC date.
Type B
01/27/2025
Section Cited
CCR
87411(f)
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87411 Personnel Requirements – General (f) All personnel ... shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified…signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents…Personnel with evidence of physical illness ... relieved of their duties. -This requirement is not met as evidenced by:
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ADM to require an S7’s updated Health Screening to indicate S7 is physically qualified to perform the duties as they are assigned. ADM to remind staff that sleeping is not allowed in the common areas. ADM to provide updated Health Screening for S7 to CCLD by POC date.
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Based on interviews conducted and records reviewed, S7 was asleep in the common area where other staff and residents could see. The incident did not result in injury; however, all staff should be capable or performing assigned task at the facility without cause for concern.
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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20240917163033
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: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
HSC
1569.269(a)(10)
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 (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidenced by:
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Licensee, ADM and all care staff are to read the Regulations, obtain personal rights training from a CCLD approved vendor. Screaming and/or yelling shall cease immediately. Proof of completed training by those listed above to be submitted by POC date.
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Based on interviews, the licensee did not comply with the section above by care staff screaming/yelling at residents which posed a potential health and safety risk to persons in care.
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7
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7
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7
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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: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7