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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 08:33:33 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
04/18/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250418151506
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:
04:00 PM
MET WITH:Annemarie Domizio, Executive Director
Justin Zackzewski, Director of Hospitality		TIME COMPLETED:
08:45 PM
ALLEGATION(S):
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Staff did not do a proper reassessment of residents care needs
Staff did not ensure residents thermostat was working properly
INVESTIGATION FINDINGS:
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On 05/02/2025 around 05:00 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced and delivered the complaint findings for the allegations. LPA met with Annemarie Domizio, Executive Director and presented the allegations.

LPA interviewed Staff (S1, S2, S3, S4, S5, S6, S7, S8), Resident #1 (R1, R2), and requested the following documents for March - April 2025: Staff Schedule, Resident Roster, Maintenance receipts/reports for facility repairs, ID/Emergency Contact information, LIC 602, Preappraisal, current Appraisal Needs and Services, Functional Evaluation, and Admission Agreement and for Residents R1.

Continued on LIC9099C...
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-20250418151506
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.

Allegation: Substantiated
Staff did not ensure residents thermostat was working properly

Interviews with staff indicated the following: On 04/22/25, S2 stated. “One of the units on the roof didn't have Freon. It affected about 3 apartments; it was the AC and the heater, and this was to regulate the temperature. On the third floor there were maybe 2 apartments affected.” S4 stated “I will admit that the temperature has been an ongoing issue and that's been about two months. S3 stated that he/she performed periodic checks in R1’s room, and that the centralized system that regulates the temperature did not indicate any fault in R1’s apartment. LPA and S4 attempted to adjust the temperature on R1’s thermostat below 77 degrees F. and thermostat continually defaulted to 77 degrees F. LPA immediately placed a service request with the concierge. On 04/30/25 S1 stated. “The HVAC system has been fixed for well over a week, we have the tech coming out tomorrow for an unrelated project and I will have him stop by the unit once again.” LPA, S3 and S2 attempted to adjust the thermostat to 80 degrees F. LPA returned after an hour and the thermostat increased 1 degree from 78 to 79, but not 80. In addition, R1’s filter needs to be cleaned.

Allegation: Substantiated


Staff did not do a proper reassessment of residents care needs

A Functional Evaluation was conduct for R1 on 10/17/25 by S2, and on 04/08/25 by S3. The 04/08/25 evaluation was initiated by S1 and R1 disagrees. The records reviewed by LPA and R1 revealed that S1, S2 and S3 did not include written record from the facility informing R1’s regular physician of the results of either functional evaluation for R1’s care needs.

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, 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-20250418151506
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
87303(b)(3)
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87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (3) Nothing in this section shall prohibit residents from adjusting individual thermostatic controls. -This requirement is not met as evidenced by:
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Licensee/ED to assess HVAC system, thermostat, and make repairs. Consult R1 about temperture range, provide proof of training with signatures, and invoices by POC date.
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Licensee/ED did not ensure the facility maintained a comfortable temperature for all residents at all times.
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Type B
05/09/2025
Section Cited
HSC
1569.80(b)
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1569.80 Care and services decision making; meeting; written record (b) Once prepared, the written record...to determine the care and services provided to the resident written record shall be sent by the facility to that physician.
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Licensee/ED to inform R1's physician by written communication, provide proof of notice to CCLD, review regulation, and certiy with signatures by POC.
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Licensee/ED did not provide written record to R1's physician for the decision making for care and services.
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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