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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 12/05/2022
Date Signed: 12/05/2022 03:09:13 PM


Document Has Been Signed on 12/05/2022 03:09 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
E BAY DELTA AC/SC, 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: 23DATE:
12/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Andrew Badoud, AdministratorTIME COMPLETED:
03:15 PM
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On 12/5/22 at 2:40PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving resident from Grand Lake Gardens (GLG) and check on resident. LPA met with Administrator and explained the purpose of the visit.

A total of 1 resident from GLG is currently living in Elegance Berkeley. During visit, LPA attempted to visit resident however the resident was out with family.

Supplies were adequate and staffing is stable.

There was no imminent health/safety concerns on today's date.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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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