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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201143
Report Date: 08/26/2025
Date Signed: 08/26/2025 03:44:51 PM

Document Has Been Signed on 08/26/2025 03:44 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/
DIRECTOR:		DOMIZIO, ANNEMARIE EFACILITY TYPE:
740
ADDRESS:2100 SAN PABLO AVENUETELEPHONE:
(510) 788-1333
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 120CENSUS: 42DATE:
08/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maureen Lee, Memory Care DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 08/26/2025 around 09:45 AM, Licensing Program Analysts (LPAs) L. Holmes and L. Alexander arrived unannounced for a required annual inspection. LPAs met with Annemarie Domizio, Executive Director (ED) and Maureen Lee, Memory Care Director (S2), and explained the purpose of the visit. ED was not available due to the activities taking place a the facility. The facility’s fire clearance was approved for one hundred twenty (120) non-ambulatory residents; ten (10) may be bedridden, and ten (10) hospice.

Upon arrival, LPAs observed multiple staff organizing a residential Hawaiian Luau, the receptionist was attending to several residents and guest visiting in the facility. LPA L. Alexander toured the facility S2. The areas included but were not limited to the common areas, dining room, bathroom, kitchen, med tech room, fitness center and courtyards. The facility consists of individual apartments housed by the residents and has a monitored floor for memory care. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at 74 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. The hot water temperature in four different rooms measured at 108 to 120 degrees (F). The shared restroom had paper towels, soap and garbage cans; all areas were safe and sanitary. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods.

...continued on LIC9099C.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 08/26/2025
NARRATIVE
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...continued from LIC9099.

Smoke detectors and carbon monoxide units were in operating condition during visit. Fire extinguisher was observed full and serviced 07/24/25. Emergency Disaster Plan is updated. Safety drills are rotational and last inspected 07/23/2025. LPA reviewed seven (7) staff files, and ten (10) resident files.

-At 11:35 AM, LPA confirmed through Guardian, and CCLD staff support that S2 was not associated to the facility; corrected during the visit.
-At 12:15 PM, LPA confirmed through observation and reviewed seven (7) out of seven (7) personnel records were incomplete; no health screenings, no first aid, insufficient training.

Deficiencies are being cited on the attached LIC 809D.

Civil penalties were assessed for $100.00/day x five (5) days.


Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

LPA L. Holmes advised ED that the use of the name, "The Arbor at Berkeley" must cease until licensed which includes but is not limited to signs, documents, flyers and announcements.



Exit interview conducted. A copy of this report and appeal rights provided to S2.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Lisha Holmes
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/26/2025 03:44 PM - It Cannot Be Edited


Created By: Lisha Holmes On 08/26/2025 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having disinfectants unlocked and unattended which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Corrected during visit. Licensee/ED to review regulations, train staff, and provide proof to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and records reviewied, the licensee did not comply with the section cited above by not maintaining personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Licensee/ED to review regulationa, update staff records, and provide proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/26/2025 03:44 PM - It Cannot Be Edited


Created By: Lisha Holmes On 08/26/2025 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not associating staff (S2) to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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CCLD assisted with association during the visit. Licensee/ED to review regulation and ensure that all staff are associated by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Lisha Holmes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2025


LIC809 (FAS) - (06/04)
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