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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 09/18/2025
Date Signed: 09/18/2025 04:32:40 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
08/27/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250827092248
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: 44DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Maureen Lee, Memory Care Director. TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not prevent resident from harassing another resident.
Staff did not provide resident with adequate food service.
Licensee did not provide adequate notice of fee increase to resident.
INVESTIGATION FINDINGS:
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On 09/18/2025 around 12:50 PM, Licensing Program Analyst (LPA) L. Holmes conducted a an unannounced initial 10-day complaint. LPA met with and explained the purpose of the visit to Maureen Lee, Memory Care Director.

During the complaint LPA Interviewed Staff (S1, S2, S3, S4, S5), Residents (R1, R2, R3, R4, R5, R6), and Witnesses (W1, W2, W3) and requested the following documents: LIC501, Resident Roster, ID/Emergency Contact information, LIC 602, Preappraisal, House Rules, current Appraisal Needs and Services, and Admission Agreement, Monthly Menu and Always Available Menus.

Allegations UNSUBSTANTIATED:

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

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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-20250827092248
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: 09/18/2025
NARRATIVE
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...continued from LIC9099.

Staff did not prevent resident from harassing another resident.

R1 stated that R2 was verbally harassing him/her multiple times. In a prior to the complaint is when R2 used a curse word towards R1. R1 did not identify any witnesses. S2 and S5 stated that R2 does have occasional outbursts which may be due to a medical condition, but there’s never anything physical towards R1. S2 stated that he/she spoke to R1 and R2 regarding the interactions suggesting sitting away from each other and/or repositioning R1's chair for avoidance, and S2 will redirect when necessary; stating that both residents have personal rights. R1 requested LPA to allow him/her to remain anonymous with R2; therefore, LPA did not interview R2. S5 stated that the allegation is not surprising because R1 will go behind the bistro bar even though R1 is not supposed to enter the area, and R1 does not want R2 to say anything about it him/her, becomes rude, screams, complains and then acts as if nothing has happened.

Staff did not provide resident with adequate food service.

LPA toured the dining area and observed breakfast and lunch being served to residents on 08/26/25 and 09/04/25. The purchase orders and invoices from Vesta and Sysco food services for the month of August 2025, were consistent with the menus provided and the meals observed. Interviews revealed that S1, S2, S3, S4, W1, W2, W3, R1, R3 and R5 did not initiate any complaints about the meals, menu of food provided; R1 was not forth coming with names, dates or times of the allegation or when the incident was reported.

Licensee did not provide adequate notice of fee increase to resident.

Interviews with (S1, S2, S3 S4), Admission records and services fees reviewed for R1, R2, R3, and R4 did not reveal any rate increases, improper notices or advance notice (60 days) notices. S1 stated there has not been any new rent rate increases since the introduction of the new management company on 07/01/2025. Hospitality.

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: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2