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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 08/21/2024
Date Signed: 09/16/2024 05:43:20 PM

Unsubstantiated


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
08/14/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240814132320
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mary Anne Watral, Operations Specialist
Douglas Blake, Executive Director		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Facility does not have an administrator on the premises
INVESTIGATION FINDINGS:
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On 09/16/2024 Amended report to correct the allegation:
On 08/21/2024 around 09:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegation. LPA met with Mary Anne Watral, Operations Specialist (OP) and Douglas Blake, Executive Director (ED) and explained the purpose of the visit.

ALLEGATION:
Facility does not have an administrator on the premises
UNSUBSTANTIATED

LPA conducted an annual inspection on 08/21/24 prior the the investigation. LPA toured the facility conducted interviews with ED and OP.
Continued from LIC9099C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240814132320
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: 08/21/2024
NARRATIVE
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...continued from LIC9099.

LPA had received written notice from the facility that the former ED has resigned and was aware that there would be an interim staff (S2, #6066818740 exp: 01/22/25) as the administrator for the allegation the facility does not have an administrator on the premises; therefore the allegation was unsubstantiated.

Exit interview conducted. A copy of this report and appeal rights were provided to 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2