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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 05/02/2025
Date Signed: 05/02/2025 07:53:19 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
04/30/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250430171112
FACILITY NAME:ELEGANCE BERKELEYFACILITY NUMBER:
019201143
ADMINISTRATOR:DOMIZIO, ANNEMARIE EFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(510) 788-1333
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:120CENSUS: 43DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Justin Zackzewski, Director of Hospitality.TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not keep all information or records regarding the resident confidential
INVESTIGATION FINDINGS:
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On 05/02/2025 around 11:00 AM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint dated 04/30/2025 #15-AS-20250430171112. LPA met with Justin Zackzewski, Director of Hospitality.

Allegation: SUBSTANTIATED
Staff did not keep all information or records regarding the resident confidential

LPA interviewed Staff (S1, S2, S3), Witnesses (W1, W2) and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, current Appraisal Needs and Services, and Admission Agreement for R1.

...continued from LIC9099.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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-20250430171112
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: 05/02/2025
NARRATIVE
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...continued from LIC9099.

On 04/21/25, S1 submitted an LIC 624 stating. “The community will be seeking a three-day discharge” for R1; no Eviction Notice was provided to CCLD at that time. On 04/24/25, LPA requested the Eviction Notice that was provided to R1. On 04/28/25, S1 emailed LPA a 30-day notice of discharge addressed to W1 dated 04/22/25. On 04/29/25, LPA advised S1, S2, and S3 via email, W1 by voicemail on 04/29/25 and by phone conversation on 04/30/25 that the Notice of Eviction presented to R1 was unlawful, and that the facility’s Licensee would be required to provide notification to R1 and R1’s responsible party that the notice would be rescinded immediately. W1 was unaware of the notice, the details, and had not received any written Eviction Notice from any representatives from the facility. W1 provided proof of a formal notice hand delivered to R1 while in the community amongst other residents. R1 is currently admitted in Memory Care (MC) and the notice contained confidential information signed by residents R2, R3, and R4, other than R1. S2 confirmed that he.she was instructed by S1 to hand deliver the notice to R1 in the presence of other residents.

Based on LPA’s 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 Tsedey Mekonnen, Concierge..

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

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20250430171112
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: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87468.2(a)(2)
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87468.2...Personal Rights of Residents in Privately Operated Facilities
(a) ...Residents in All Facilities...shall have all of the following personal rights:
(2) To have their records and personal information remain confidential...
-This requirement is not met as evidenced by:
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Licensee/ED to review regulation and ensure that all residents records are presented and maintained with confidentiality. Provide in-service training for Care Staff, and signatures as proof.
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Licensee/ED did not ensure that R1's and RP's records be presented and maintained with confidentiality.
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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: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3