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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 09/16/2024
Date Signed: 09/16/2024 05:52:25 PM


Document Has Been Signed on 09/16/2024 05:52 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:
09/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Douglas Blake, Interim-Executive DirectorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 09/16/2024 around 01:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and conducted a case management as a result. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit.

During the course of the visit, LPA conducted interviews with RP, ED and requested Resident (R1)’s file including, but not limited to the following documents from R1’s file: Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, UIR’s and faxes.

-At 03:00 PM, LPA confirmed that Licensee did not report blood in R1’s urine on different occasions in April, July and August of 2024.
-At 03:10 PM, LPA confirmed that R1 who has Dementia did not have an updated Physician’s Report (LIC602) or Reappraisal since 09/29/2022.
-At 03:15 PM, LPA confirmed that there were medication errors on R1’s Medication Notification List faxed to the physician on 08/22/24. Staff did not report medication error to CCLD.
-At 03:40 PM, LPA confirmed that there were medication errors on R1’s Medication sheet dated August 2024. Staff did not hold (discontinue) R1's medication starting 08/12/24 per physician's order.

An immediate civil penalty of $250 is hereby assessed for the day of 09/16/24.

Deficiencies cited from Title 22 California Code of Regulations and listed on LIC809D. 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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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 09/16/2024 05:52 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: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:

(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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ED to coordinate with R1’s Responsible Party/Conservator to schedule a medical assessment and reappraisal on or before 09/18/2024.
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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 an update annual medical assessment and reappraisal which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/18/2024
Section Cited
CCR87211(a)

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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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ED agreed to report all major occurrences within 24 hours and submit incident reports within seven days to CCLD.
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Based on observation, interviews and record review, the Licensee did not comply with the section cited above by not reporting R1’s UIR's to CCLD.
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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: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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