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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 12:12:35 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
12/16/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241216095924
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: 42DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Justin Zackzewski, Director of HospitalityTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff allowed a resident to be soiled while in care

Staff mishandled a resident's medication while in care
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 Director of Hospitalitys, 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 S1 toured the facility on 12/20/24; LPA 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...
Substantiated
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 3
Control Number 15-AS-20241216095924
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 allowed a resident to be soiled while in care

W2 reported he/she arrived at the facility for his/her shift t and found R1 was left in soiled clothing and sheets with feces. W2 report the incident to W1. W2 stated he/she saw S5, and S6 that morning and was not sure why no one had responded to R1. W2 stated all the caregivers or housekeeping would have had to do is put R1 in the shower. It was about 9:00 AM when S10 was passing the medications. It took S10 about 3 hours to comeback regarding R1’s ingrown toenails. W2 asked S10 to please give R1 the Imodium A-D for diarrhea; R1 was having stomach issues. W2 stated. “The one thing that is wrong with the facility for sure is that there are no nurses.” S4 was not at the facility that day. According to W2, S10 finally called someone, and it was about 1:00 – 2:00 PM before R1 received the medication to relieve the diarrhea. LPA interviewed W3, and W4, and both stated that they have had incontinence concerns with the facility also.

Staff mishandled a resident's medication while in care

Records requested and interviews with W1 and W2 revealed that R1 is prescribed Imodium A-D. The Medication Sheet has two separate and different entries for R1’s Centrally Stored Medication; neither were notated as being administered for 12/2024. LPA reviewed R1’s Physician’s Report (LIC602); LPA reviewed R1’s Progress Notes and there was not any notation or refusal for the month 12/2024. Interviews with W1 and W2 reveal that R1 had an incident with diarrhea and vomiting on or around 12/16/24. S10 administered Imodium (A-D); however, the time, date and dosage is unknown and was not recorded on any day of R1's Medication Sheet for the month 12/2024.

Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiency is 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 Justin Zackzewski, Director of Hospitality.

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 3
Control Number 15-AS-20241216095924
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: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
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/ED 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. ED to review regulations, self-certify and provide CCLD a current/updated schedule for each shift by POC date.
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Based on interviews and records reviewed, the license did not comply with the section above by not having sufficient and competent number of staff to meet bowel and incontinence care needs.
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Type A
04/04/2025
Section Cited
CCR
87465(d)
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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...unable to communicate his/her symptoms clearly, facility staff designated by the licensee...
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Licensee/ED to assure trained staff are available to assist residents as needed with medications, document refusal date, time, follow physician’s orders, reconcile medication lists, & perform staff training for all personnel that administers medication. Submit proof of procedures with names of attendees to CCLD by POC.
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 -This requirement is not met as evidenced by:
Based on interviews and records reviewed, Licensee did not assure residents received administration of medication(s).
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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: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3