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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 03/28/2024
Date Signed: 03/28/2024 07:06:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/20/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240320153953
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: 45DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Executiuve Director Robert CoeTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Staff are not rendering services as agreed in the resident's Admission Agreement
Staff are not providing daily activities for residents
INVESTIGATION FINDINGS:
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On 3/28/2024 at 11:15 AM, Licensing Program Analysts (LPAs) J. Sampair and L. Holmes arrived at the facility unannounced to conduct the initial 10-day complaint investigation of the allegations above. Upon entry, the LPAs informed Executive Director (ED) Robert Coe of the purpose of the visit.

The complaint alleges that staff are not rendering services as agreed in the resident's Admission Agreement.

On 3/28/2024, the LPAs observed Resident R1, R1’s dog Cloud, R1’s room and the Memory Support area, interviewed the ED and Director of Health and Wellness Tea James, reviewed R1’s Admissions Agreement dated 11/18/2022, Functional Evaluation dated 10/5/2023, Service Plan dated 3/28/2024, and the Operations Procedures issued 4/1/2023 and revised 10/15/2023 entitled “Pets Residing In or Visiting Community”. Based on these document reviews, interviews, and observations, the LPAs concluded that staff are rendering services as agreed in the resident's Admission Agreement.

Report Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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-20240320153953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELEGANCE BERKELEY
FACILITY NUMBER: 019201143
VISIT DATE: 03/28/2024
NARRATIVE
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...Report Continued from LIC9099

The complaint alleges that staff are not providing daily activities for residents.

On 3/28/2024, the LPAs interviewed the ED and Director of Health and Wellness Tea James, reviewed the facility’s March 2024 Activities calendars for Assisted Living and Memory Support, and observed 20 residents in Memory Support interacting with 10 Staff Members. Based on these interviews and observations, the LPAs concluded that daily activities are being provided.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with ED Coe and Director James. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2