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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 08/22/2022
Date Signed: 08/22/2022 01:17:06 PM


Document Has Been Signed on 08/22/2022 01:17 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:BADOUD, ANDREWFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(951) 310-0024
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:120CENSUS: 0DATE:
08/22/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Andrew Badoud, Executive Director (ED)TIME COMPLETED:
01:30 PM
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On 08/22/2022 at 01:20 PM, Licensing Program Analysts (LPAs) L. Holmes and Meenakshi Malik arrived announced to conduct a Pre-licensing Inspection. While at the facility for Prelicensing, LPAs completed a Component III presentation with Andrew Badoud, Executive Director (ED), Nicole Dockson, Vice President (VP), and Angelica Gonzalez-Gillam, Director of Health and Wellness.

LPAs discussed the COVID-19 infection control requirements, the importance of attending the informational calls, understanding the updated guidelines and printing the provider information notices (PINS) for clients, authorized representatives and staff so that the facility maintains awareness and updates for compliancy with the Title 22 regulations.

-Component III completed.

Exit interview conducted and a copy of this report provided to Andrew Badoud, Executive Director.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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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