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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 07/30/2024
Date Signed: 07/30/2024 04:49:50 PM


Document Has Been Signed on 07/30/2024 04:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 48DATE:
07/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Robert Coe, Executive Director TIME COMPLETED:
01:00 PM
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On 07/30/24 around 10:30 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for an "Elopement" of Resident #1 (R1). LPA met with Robert Coe, Executive Director (ED) and explained the purpose of the visit.

On 07/29/24, ED reported that there had been an elopement of R1 on that same day, an Unusual Incident Report (UIR) would follow, R1's son returned R1 to the facility, and R1 now resides in Memory Support. R1 was admitted to the Assisted Living (AL) unit of the facility on 07/26/24. R1’s family was to assist with R1 transitioning from home to the facility throughout the weekend. On 07/29/24, R1 left the facility walking his/her dog but the facility staff was unaware that R1 was alone. While out of the facility in the community, R1 started feeling faint and asked a passerby to use their phone. The Berkeley Fire Department (BFD) was contacted and in turn BFD alerted W1 and the facility that R1 would be transported to Alta Bates Hospital in Berkeley, CA for further observation. W1 contacted ED regarding R1’s assessment and returned R1 to the facility the same day. Staff (S2) reassessed R1, completed a new functional evaluation that now includes wandering, exit seeking behaviors, MCI and a terminal illness that qualifies R1 for Memory Support that further includes photos of new resident's at the front desk, photos at the assisted living and memory support units, photos on the E-MAR and on the file face sheets.

No deficiencies cited.

Exit interview conducted and a copy of this report provided to Robert Coe, Executive Director.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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