019201143-9-16-2024-15-AS-KHOS-D9FSMH-20240925135957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 08/21/2024
Date Signed: 09/16/2024 05:42:43 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
08/14/2024 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240814132320

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: 48	DATE:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Anne Watral, Operations Specialist Douglas Blake, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Uncleared adults 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:
Uncleared adults on the premises
SUBSTANTIATED

Deficiency was cited on LIC809D on 08/21/24 under the annual inspection.
Exit interview conducted. A copy of this report and appeal rights were provided to ED.

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: 09/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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