019201143-12-10-2025-15-AS-BFOG-DPGVFH-20251218152357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 12/10/2025
Date Signed: 12/10/2025 04:23:14 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
12/01/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20251201102255

FACILITY NAME:	ARBOR AT BERKELEY		FACILITY NUMBER:	019201143
ADMINISTRATOR:	DOMIZIO, ANNEMARIE E		FACILITY TYPE:	740
ADDRESS:	2100 SAN PABLO AVENUE		TELEPHONE:	(510) 788-1333
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94710
CAPACITY:	120	CENSUS: 41	DATE:	12/10/2025
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Sarina Lichtenberger, Regional Operations Leader Justin Zackzewski, Associate Executive Director Maureen Lee, Administrator/Memory Care Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff does not prevent resident from being verbally abusive to other residents
Staff charging resident for services not received

INVESTIGATION FINDINGS:

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On 12/10/25 at 1:18PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (Regional Operations Leader (ROL), Associate ED (AED), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ROL and AED.

During investigation, LPA interviewed staff (ROL, AED), random residents (R1, R2, R3) and obtained the following documents from AED - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Appraisal/Needs & Services plan, monthly invoices and incident reports.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20251201102255

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: ARBOR AT BERKELEY	FACILITY NUMBER: 019201143
	VISIT DATE: 12/10/2025

NARRATIVE

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Allegation: Staff does not prevent resident from being verbally abusive to other residents
Investigation Finding: Unsubstantiated
On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED), staff incident statements and reviewed R1’s documents. ROL stated that they have had two in person meetings with R1 and R2 to address and mitigate their verbal altercations. AED stated that on 11/20/25 after residents had their lunch, staff (S1,S2) safely redirected R2 back to his room when he started yelling at R1 when she purposely provoked R2 to make him more angry. Prior LPA L Holmes' interviews with residents (R1,,R3, R4) on 09/04/25 confirmed that staff safely redirected and separated R1 and R2 whenever they had a heated argument. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff does not prevent resident from being verbally abusive to other residents is unsubstantiated.

Allegation: Staff charging resident for services not received
Investigation Finding: Unsubstantiated
On 12/10/25 at 1:20PM, LPA interviewed staff (ROL, AED) and reviewed R1’s documents. Review of R1’s signed service plan agreement dated 04/22/25 showed R1 agreed to pay the Level I Assisted Living Care monthly charge of $960.48 effective 05/13/25. AED stated the change of monthly charge was due to the switch from Elegence at Berkeley Service Plan point system to the new Arbor at Berkeley Level of Care Plan system. Staff (ROL,AED) stated they explained the monthly service rate change to R1 and did not bill her the Level 1 Care package until 07/01/25 with a monthly discount of $200. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff is charging resident for services not received is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

LIC9099 (FAS) - (06/04)

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