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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 03/28/2025
Date Signed: 03/28/2025 12:31:12 PM

Unsubstantiated


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
01/08/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250108114401
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: DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Justin Zackzewski, Director of Hospitality TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not provide resident medication as requested.
INVESTIGATION FINDINGS:
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On 03/28/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the finding for the above allegation. LPA met with Staff, Justin Zackzewski and explained the purpose for the visit; Concierge stated that Annemarie Domizio, Executive Director should arrive around 10:00 AM.

During the course of the investigation and visit, LPA and Licensing Program Manager (LPM) Y. Flores-Larios met with Interim Executive Director (ED) and onboarding Executive Director (ED) Annemarie Domizio on 01/14/25. LPA and ED toured the facility, LPA and LPM requested, and reviewed the following, but not limited to staff roster, resident roster, resident records, including but not limited to Residents' (R1, R2, R3): LIC602, ID/Emergency Contact information, Progress Notes, Centrally Stored Medications/Destruction Records, Medication Sheet, Functional Evaluations, and Physician's Orders. LPA conducted resident, staff and witness interviews.

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

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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 2
Control Number 15-AS-20250108114401
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: 03/28/2025
NARRATIVE
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...continued from LIC9099.

Staff did not provide resident medication as requested.

LPA reviewed a sample of two dates from R1’s Medication Notes, and Progress Notes before around the alleged time frame that R1’s medication was mishandled during December 2024. R1 is prescribed Milk of Magnesia (PRN) for nighttime. On 12/18/24, the Medication Sheet revealed that S11 administered PRN at 03:24 AM; progress notes revealed that PRN was requested by R1 at 9:00 PM but not administer by S8 which is noted on the Medication Sheet. On 12/19/24, S12 administered PRN at 08:53 PM and noted that R1 requested PRN again at 11:00 PM. Records do not reflect that there was any medication administered in error, and R1 was administered his/her prescribed Metamucil for the entire month of December as prescribed except when R1 refused on 12/18/2024. R1 and W1 could not identify specific PRNs and/or prescribed medications that weren’t administered when requested according to the physician’s orders.

Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has not been met; therefore, the above allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

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

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2