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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 06/11/2025
Date Signed: 06/11/2025 04:25:28 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
04/22/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250422160308
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: 45DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Justin Zackzewski, Director of HospitalityTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not ensuring that resident(s) receive their medications as necessary.
Staff are not adequately supervising resident(s) in care.
Licensee does not ensure that medical staff are able to communicate with staff regarding residents in care.
Facility fax is in disrepair.
INVESTIGATION FINDINGS:
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On 06/11/2025 around 12:00 PM Licensing Program Analysts (LPA) L. Holmes and Y. Brown conducted an unannounced complaint visit to deliver the findings for the above allegations. Annemarie Domizio, Executive Director was in a meeting during the visit. LPA presented the allegations Justin Zackzewski, Director of Hospitality. Amended reported to make public.

LPAs conducted interviews with Residents (R1, R2, R3), Staff (S1, S2, S3, S4, S5, S7), and Witnesses (W1, W2).. LPAs requested the following documents for February 2025 - May 2025: R1's records, MAR, Staff Schedule, Resident Roster, ID/Emergency Contact information, and personnel files for disciplinary action.

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

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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 5
Control Number 15-AS-20250422160308
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: 06/11/2025
NARRATIVE
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...continued from LIC9099.

Allegations: SUBSTANTIATED

Staff are not ensuring that resident(s) receive their medication's as necessary.


S6 reported on R1’s progress notes dated 03/15/2025 that R1 last received Sertraline on 03/12/25; The Electronic Medication Administration Records (EMAR) further reports that Omnicare and Elegance Berkeley had two different attending physicians. As a result, W1 wrote a prescription on 03/17/25 and W2 provided the medication to the facility for R1. S6 stated that the R4’s medication was discontinued on 02/28/25, but R4 missed the medication for two days, R4’s family was not notified, and the doctors were not aware. S6 states, “Staff are not properly trained.”

Staff are not adequately supervising resident(s) in care.
On 03/04/25, S8 documented on R1’s progress notes that R1 was found outside by the corner of the facility. Records and interviews with S1, S2, S5, S6, S7 and W2 revealed that R1 has exited Memory Care and had wandering behaviors in March and April of 2025. On 04/14/25, R1 exited from Memory care to the 1st floor without any staff witnessing the elopement. On 04/28/25, W2 requested that R1 take a stroll with the Care Companion (1:1), action was denied by S1 and S5. S2 confirmed that R1 was unable to leave with the 1:1 because the staff were trying to get R1 acclimated to residing in Memory Care.

Licensee does not ensure that medical staff are able to communicate with staff regarding residents in care.
W1, and S5 stated that the fax machine was not working but was not able to confirm the fax number; W1 stated the date was around January 2025. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility dated 04/2025. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax, and was last tested 01/28/25 per records reviewed.

Continued on LIC9099C.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250422160308
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: 06/11/2025
NARRATIVE
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...continued from LIC9099C.

Facility fax is in disrepair.
W1, and S5 stated that the fax machine was not working but was able to confirm the fax number. LPA confirmed that the fax number 510-788-XXXX is not working per the notification on the fax cover sheet from the facility. W1 was not able to confirm the correct fax number because the facility had not given W1 any advance notification. LPA confirmed that 510-705-XXXX is a working fax and was tested on 01/28/25.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies 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: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250422160308
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: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2025
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 that trained staff are available to assist residents as needed with medications, follow physician’s orders, perform staff training for all personnel that administers medication. Submit names of attendees to CCLD by POC.
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assist the resident with self-administration...
-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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Type A
06/13/2025
Section Cited
CCR
87411
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The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal.
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Licensee/ED to review resident records, LIC602, preappraisal needs and services to ensure sufficient trained staff are available for the care and services of all residents. LIC & staff to certify with signatures that the regulation has been reviewed by POC.
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-This requirement is not met as evidenced by:

Supervision was not present to assist R1 with exit seeking behaviors per R1's physician's report.
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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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250422160308
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: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2025
Section Cited
HSC
1569.80
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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.-This requirement is not met as evidenced by:
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Licensee/ED to inform all physicians and pharmacies of the correct form of communication by fax, email and landline. Provide proof of notification to CCLD on or before completion date of 06/18/25.
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Licensee/ED did not confirm contact information was correct for notifications of residents' services from physicians and pharmacies.
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Type B
06/11/2025
Section Cited
CCR
87303
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.-This requirement is not met as evidenced by:
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LPA tested and confirmed that the fax machine is working.
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Licensee/ED presented two different fax cover sheets and could not confirm when fax number 510-788-XXXX was no longer working.
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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: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5