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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 08/21/2024
Date Signed: 08/22/2024 04:28:57 PM


Document Has Been Signed on 08/22/2024 04:28 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:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH: Mary Anne Watral, Operations Specialist
Douglas Blake, Executive Director		TIME COMPLETED:
05:30 PM
NARRATIVE
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On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced for a required annual inspection. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit. The facility’s fire clearance was approved for two hundred twenty-five (225) non-ambulatory residents; fifty (50) may be bedridden.

Upon arrival, LPA observed one (1) staff attending the receptionist desk, and several residents visiting in the facility's common area along with others eating breakfast. LPA toured the facility with OP and ED. The areas included but were not limited to, common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored unit for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 73 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in the shared restroom on the 2nd floor was measured at 117.1 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There is a 2-day supply of perishable foods and a 7-day supply of non-perishable foods.

...continued on LIC9099C.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/21/2024
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...continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and serviced 07/16/24. Emergency Disaster Plan is updated. Safety drills are rotational between monthly. LPA reviewed five (5) staff files, and seven (7) resident files.

-At 10:15 AM, LPA confirmed through Guardian, and CCLD staff support that ED did not have criminal record clearance on file and was not associated to the facility.
-At 01:25 PM, LPA confirmed through observation and review that seven (7) out of seven (7) personnel records were incomplete. OP and ED to review and update all files.

Deficiencies are being cited on the attached LIC 809D.

Civil penalty was assessed for $100.00/day


Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to OP and ED.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/22/2024 04:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by person, Executive Director (ED) not having criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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ED notified their corporate office of the deficiency and was background cleared and associated to the facility in Guardian on 08/21/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3