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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 07/08/2025
Date Signed: 07/08/2025 02:45:11 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
02/25/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250225105631
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:
07/08/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Justin Zackzewski, Director of HospitalityTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff working while under the influence of alcohol.
Staff disrespectful to residents and residents' families.
INVESTIGATION FINDINGS:
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On 07/02/2025 around 02:15 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.

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: Staff Schedule, Resident Roster, ID/Emergency Contact information, and personnel files for disciplinary action.

Continued on LIC9099C...

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

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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-20250225105631
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: 07/08/2025
NARRATIVE
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...continued from LIC9099.

Allegations: UNSUBSTANTIATED

Staff working while under the influence of alcohol.

The reporting party remained anonymous; however, S1 and S2 thinks they know who initiated the complaint. LPA reviewed personnel records for disciplinary actions against staff from February 2025 - May 2025, no records revealed any misuse of alcohol while staff were on duty. On 02/25/25, S2 stated that S3 was being mean towards S1; it wasn't right. S3 was looking for S1 with a disgusting look (teasing). S1 stated that the complaint has no merit and S1 is not comfortable being with S3. S3 stated that he/she did not want to mention who told him/her that S1 smells like alcohol because S3 doesn’t want to get them in trouble. S1 stated that S3 said he/she smelled tequila. S2, S3, S6, R1, R2, and R3’s interviews did not reveal any witnessing or knowledge of any staff working while under the influence of alcohol.

Staff disrespectful to residents and residents' families.

R1 stated that everything is okay at the facility. R1 said he/she had not met or talked to S1 yet, but R1 has seen S1. R2 thinks he/she is getting what R2 needs, but has not met S1, and has lived at the facility for over 2 years. R3 said he/she has only talked or interacted with S7, and “S7 is realistic about what’s going on.” R3 has not met S2 or S1.

Based on information obtained, the allegations are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met.

Exit interview conducted, 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: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2