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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:29:21 PM


Document Has Been Signed on 09/11/2024 01:29 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: 49DATE:
09/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Douglas Blake, Executive DirectorTIME COMPLETED:
11:15 AM
NARRATIVE
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On 09/11/2024 around 9:50 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management. LPA met with Douglas Blake, Executive Director (ED) and explained the purpose for the visit.

On 09/10/24, Licensing Program Analyst (LPA) L. Holmes requested R1’s LIC602 and LIC624 related to the R1’s Elopement. On 09/09/24, Licensing Program Analyst (LPA) T. Syess-Gibson conducted a phone interview per the request of Licensing Program Manager (LPM) to inquire about an AWOL that took place on 09/08/24 around 4:30 PM. LPA T. Syess-Gibson spoke with (S1), and explained the purpose of call. S1 offered to take the number and have Douglas Blake, Executive Director (ED) call back.



At around 11:05 AM LPA T. Syess-Gibson received a call from Douglas Blake, Executive Director advising that the AWOL happened on 09/08/2024 at approximately 4:30pm with an Assisted Living Resident #1 (R1). S2 noticed R1 was missing and had left the community without signing out. The Berkeley Fire Department found the resident around 6:45-7:30 PM, and took the R1 to Alta Bates Hospital for observation hospital for observation.

Per ED, the Aftercare Summary Report indicated a change in condition for R1 as an altered mental status. ED state that he has a call scheduled with the family to discuss R1’s long term care needs. LPA T. Syess-Gibson advised ED to send in the incident report as soon as possible. LPA T. Syess-Gibson provided ED with her email address and the office’s general email address.

On 09/11/24 during the visit, ED confirmed that R1 can't leave unassisted and R1 may have left during the change of shifts at the Concierge area. Training on policies and procedures took place on 09/11/24. Unannounced drills will follow monthly along with bringing the teams together to review the policies, procedures, timelines, and debriefing regarding AWOLs/Elopements.

continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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: 09/11/2024
NARRATIVE
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continued from LIC809...

R1's responsible party and Berkeley Police Department were alerted immediately; however, Community Care Licensing was not notified until 09/09/24.

-At 12:10 PM, LPA interviewed S2 and confirmed that S3 stated that he/she tested positive for COVID on or around 09/07/24; the incident was not reported to CCLD via telephone or fax.

Based on information obtained, deficiencies are 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.

An immediate civil penalty was assessed of $250 is hereby assessed on 09/11/2024.



Exit interview conducted, Appeal Rights, and a copy of this report provided to Douglas Blake, Executive Director.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/11/2024 01:29 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: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia
(b) In addition...specified in Section 87208…(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
-This requirement is not met as evidenced by:
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ED completed the following and will submit proof by 09/13/24.
1. In-service the staff training
2. Inform Concierge staff of residents are unable to leave the facility unassisted.
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Based on interviews and records review, the licensee did not comply with the section above when R1 in Assisted Living was able to leave unassisted and unnoticed which posed an immediate safety risk to persons in care.
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Type B
09/18/2024
Section Cited
CCR87211(a)(2)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(2) Occurrences, such as epidemic outbreaks, shall be reported within 24 hours either by telephone or facsimile to the licensing...
-This requirement is not met as evidenced by
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Administrator agreed to report all major occurrences within 24 hours and submit incident reports within seven days to CCLD by POC date.
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Based on observation and record review, the Licensee did not comply with the section cited above in
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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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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