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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 09/03/2024
Date Signed: 09/03/2024 01:03:52 PM


Document Has Been Signed on 09/03/2024 01:03 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:
09/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Douglas Blake, Executive DirectorTIME COMPLETED:
01:15 PM
NARRATIVE
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On 09/03/2024 around 12:00 PM, Licensing Program Analyst (LPA) L. Holmes conducted a case management as result of an unannounced initial 10-day complaint visit. LPA met Douglas Blake, Executive Director (ED).

During the course of the investigation and visit, LPA conducted interviews and requested R1's file including, but not limited to the following documents: Centrally Stored Medication Log, Medication Administration Records and Physician's Report (LIC602).

-At 10:50 AM, LPA and ED reviewed R1's latest LIC 602 dated 06/06/2023.

Deficiency cited to LIC D. Failure to correct the deficiency 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 ED.




SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024
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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Document Has Been Signed on 09/03/2024 01:03 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: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who...retain residents with dementia shall be...ensuring the following:(5) ...annual medical assessment...reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
-This requirement is not met as evidenced by
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ED to coordinate with R1 and R1’s Responsible Party to schedule a medical assessment and reappraisal on or before 09/10/2024.
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Based on observation, interviews and record review, the licensee did not comply with the section cited above by person, Resident (R1) not having an updated annual medical assessment and reappraisal which poses an immediate health, safety or personal rights risk to persons in care.
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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: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024
LIC809 (FAS) - (06/04)
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