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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:41:30 PM

Document Has Been Signed on 02/05/2025 04:41 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: 47DATE:
02/05/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Claudia Redditt, Director of Business Administration TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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On 02/05/2025 around 01:35 PM, LPA amended complaints 15-AS-20241223152240 and 15-AS-20241223091751 to update the continuation pages. Executive Director (ED), Annemarie Domizio suggested that Licensing Program Analyst (LPA) L. Holmes meet with Claudia Ridditt, Director of Business Administration (S1) due to ED's time constraints.

LPA interviewed S5 to review the coding for the Medication Administration Records (MAR) and confirmed there will be initials for administration of medication, an 'X' or a blank space with progress notes for an explanation.

On 01/21/2025, LPA requested ED provide proof that Residents (R2, R3, R4, R5) and their responsible parties were provided with a current incontinence care plan for the plan or correction on complaint 15-AS-20240917163033. On 01/28/25, LPA received the POC for training and updated care plans; however there were not any emails, faxes, or signed incontinence care plans from residents and RPs to confirm they were aware of the updates; during the visit, S1 and LPA reviewed signed copies for R1 and R3. S1 stated that they were awaiting the signed electronic documents from R5, and R2 had passed away.

- Around 3:15 PM, LPA requested a Death Report (LIC624A) that revealed R2's date of death was 01/02/2025 and was reported to Community Care Licensing (CCL) 01/21/2025.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, a copy of the appeal rights, and this report provided Claudia Redditt, Director of Business Administration (S1)

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 02/05/2025 04:41 PM - It Cannot Be Edited


Created By: Lisha Holmes On 02/05/2025 at 03:48 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: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2025
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ... (1) A written report ... within seven days of the occurrence of any of the events specified in (A) through (D) below ... (A) Death of any resident
-This requirement is not met as evidenced by:

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ED to review the regulation, self-certify, and provide proof to CCL by POC date.
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Based on interviews and records reviewed, the Interim ED did not comply with the section above by not providing a written report of death for R2 within seven (7) days which poses/posed a potential health and safety 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: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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