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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:49:39 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/04/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240304111743
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: 49DATE:
05/02/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Robert CoeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not provide adequate supervision resulting in a resident eloping from the facility.
INVESTIGATION FINDINGS:
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On 5/2/2024 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at the facility unannounced to deliver the findings pertaining to the allegation above. Upon entry, the LPA informed Executive Director (ED) Robert Coe of the purpose of the visit.

The complaint alleges that facility staff did not provide adequate supervision resulting in a resident eloping from the facility.

On 3/8/2024 and 3/28/2024, LPAs G. Luk, L. Holmes, and J. Sampair visited the facility and interviewed the ED and 3 staff members, collected and reviewed resident and facility reports, examined the egress doors the "Safely You" alert devices, and the alarm added by the facility after the elopement. The ED stated that there had never been a problem with anyone exiting through the service elevator before and that R1 did not exhibit exit seeking behavior.

Report Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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-20240304111743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 05/02/2024
NARRATIVE
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...Report Continued from LIC9099

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

No citations issued during visit.

Exit interview conducted with ED. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2