019201143-9-11-2024-15-AS-KHOS-D93QBU-20240913120206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:50:46 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
08/30/2024 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240830161136

FACILITY NAME:	ELEGANCE BERKELEY		FACILITY NUMBER:	019201143
ADMINISTRATOR:	COE, ROBERT		FACILITY TYPE:	740
ADDRESS:	2100 SAN PABLO AVENUE		TELEPHONE:	(510) 788-1333
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94710
CAPACITY:	120	CENSUS: 49	DATE:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Douglas Blake, Executive Director and Keoni Myles, Director of Health and Wellness		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff mismanaged resident's medications.

INVESTIGATION FINDINGS:

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On 09/11/2024 around 11:15 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the finding for the above allegation. LPA met with Douglas Blake, Executive Director (ED) and Keoni Myles, Director of Health and Wellness, and explained the purpose for the visit.

Allegation:
Staff mismanaged resident's medications.

During the course of the investigation and visit, LPA conducted interviews with ED, Staff (S1) and Resident #1 (R1)'s. LPA requested R1’s file including, but not limited to the following documents: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes.

Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240830161136

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: 09/11/2024

NARRATIVE

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continued from LIC9099.

During the course of the investigation, interviews and records reviewed revealed that on 09/07/23 and 10/21/23, S2 and S3 faxed notices to R1’s physician stating that R1 had been refusing to take his/her medication and requested that the physician advise R1. R1’s medication lists dated 09/20/23, 04/26/24 and 09/03/24 states that R1 has routine medication in the morning and evening (9:00 AM and 6:00 PM) and as needed based on R1’s systolic blood pressure. Records reviewied and interviews revealed that the facility did not have any record of R1’s refusal for medication, record of times of medication administration and there was not any notation or records of R1’s blood pressure. ED attempted to locate the information but stated that they were unable to recover the online data that was managed by a third-party vendor and a MAR was not utilized.

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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240830161136

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: 09/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/13/2024 Section Cited CCR 87506(b)(10)	1 2 3 4 5 6 7	87506 Resident Records(b) Each resident’s record shall contain at least the following information:(10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.-This requirement is not met as evidenced by	1 2 3 4 5 6 7	ED to coordinate with R1’s physician’s to consolidate R1’s medication lists, document refusals date and time, follow physician’s orders, and perform staff training for all personnel that administer medication and submit proof with names of attendees to CCLD on or before 09/13/24.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the licensee did not comply with the section above when R1's refusals, blood pressure, and medication administered with all three dates and times were not documented posed an immediate safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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