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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 07/30/2024
Date Signed: 07/30/2024 05:30:26 PM

Substantiated


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
06/11/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240611092951
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert Coe, Executive DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility did not provide family with requested resident records.
INVESTIGATION FINDINGS:
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On 07/30/2024 around 10:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegationa and to conduct a case management. LPA met with Robert Coe, Executive Director (ED) and explained the purpose for the visit.

Allegations:
Facility did not follow COVID procedures.
Facility did not provide family with requested resident records.

During the course of the investigation and visit, LPA conducted interviews with ED, Staff (S1) and Respsonsible Party (RP). LPA requested resident #1 (R1)'s file including, but not limited to the following documents: Current Personnel Report (LIC 500), LIC 500 dated 09/2023 and 06/2024, Resident Roster, facility’s COVID-19 protocol for 09/2023 & 10/2024 along with email, UIR's or copies of family notification for COVID-19 cases.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20240611092951
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: 07/30/2024
NARRATIVE
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Continued from LIC9099

R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023.

Allegation: Facility did not provide family with requested resident records.
SUBSTANTIATED

R1’s Responsible Party (RP) stated that on October 13, 16, 20, 21, and 24, 2023, that she/he had requested records pertaining to R1 and never received a response. ED does not have record of who the request was sent to at the facility. ED did not have who the POA was on record. On 06/14/24, interviews with Staff (ED and S1) revealed that R1’s resident files had not been provided to RP and there was not a POA on record. LPA spoke to ED and S1 on 07/16/24 and both stated that R1’s records would be sent to CCLD by the end of July. The facility did not provide family with requested resident records; therefore, the allegation is substantiated.

Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240611092951
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87506(c)(1)
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87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential...(1) The licensee shall...reveal or make available...upon the resident's written consent or that of his designated representative.

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Executive Director/Licensee to read the regulations, provide training to staff, submit proof of attendee’s signatures, and devise a plan to ensure that proper notification is provided to residents and residents’ responsible party’s in a timely matter of 72 hours.
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-This requirement is not met as evidenced by

-Based on interviews and observation, the Licensee did not comply with the section above by not providing R1’s RP with the resident’s records.
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Executive Director/Licensee to provide R1’s records to the RP.

-R1's records provided to LPA by ED during visit on 07/30/2024.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/11/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240611092951

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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert Coe, Executive DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
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Facility did not follow COVID procedures.
INVESTIGATION FINDINGS:
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On 07/30/2024 around 10:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegation and to conduct a case management. LPA met with Robert Coe, Executive Director (ED) and explained the purpose for the visit.

Allegations:
Facility did not follow COVID procedures.
Facility did not provide family with requested resident records.

During the course of the investigation and visit, LPA conducted interviews with ED, Staff (S1) and Respsonsible Party (RP). LPA requested R1's file including, but not limited to the following documents: Current Personnel Report (LIC 500), LIC 500 dated 09/2023 and 06/2024, Resident Roster, facility’s COVID-19 protocol for 09/2023 & 10/2024 along with email, UIR's or copies of family notification for COVID-19 cases. Continued on LIC9099C...

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240611092951
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: 07/30/2024
NARRATIVE
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...continued fron LIC9099.

R1’s ID/Emergency contact information, most recent Physician’s Reports and the report that the covers 09/2023 along with After Visit Summaries, Case Notes, and Centrally Stored Medication lists for 09/2023 - 10/2023; facility’s emails, faxes, call logs and/or any other correspondences with R1's Responsible Party (RP) and Primary Care Physician for 09/2023 and 10/2023.

Allegation: Facility did not follow COVID procedures.
UNSUBSTANTIATED

On 04/06/23 California Department of Social Services (CDSS) presented PIN 23-07-ASC related to the COVID-19 pandemic following the end of the COVID-19 State of Emergency (SOE) on February 28, 2023, as guidance and to update licensees of Adult and Senior Care (ASC) facilities. On March 3, 2023, the California Department of Public Health (CDPH) terminated several State Public Health Officer Orders. Screening for COVID-19 signs, symptoms, and exposure were recommended for residents and visitors through passive screening measures but was not required. According to PIN 23-13-ASC, the licensee followed regulations related to infection control, prevention and mitigation for communicable diseases by maintaining an Infection Control Plan (ICP) and reporting the incident to Community Care Licensing (CCLD) on September 13, 2023; therefore, the facility did follow the COVID-19 procedures, and the allegation is unsubstantiated.

No deficiency 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5