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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 07:02:39 PM

Substantiated


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
01/02/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240102100222
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:Executive Director Robert CoeTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Unlawful eviction
Staff did not provide resident's POA with requested documents
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 deliver the findings pertaining to the allegations above. Upon entry, the LPAs informed Executive Director (ED) Robert Coe of the purpose of the visit.

The complaint alleges that residents were being unlawfully evicted.
Review of the eviction letter dated 12/5/2023 by the LPAs revealed that it was unlawful.

Report Continued on LIC9099-C...
Substantiated
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 3
Control Number 15-AS-20240102100222
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 did not provide resident's POA with requested documents.

Review of R1’s Admissions Agreement dated 11/18/2022 by the LPAs revealed that it was missing the Resident Handbook and that communications by the facility with R1’s POA did not provide the requested documents.

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED.

Deficiency is cited under the California Health and Safety Code listed on LIC9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with ED Coe. 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 3
Control Number 15-AS-20240102100222
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87224(f)
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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement was not met as evidenced by:
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On or before the due date, the Licensee shall inform the POA that the 3/7/2024 letter to evict was not valid. The ED shall inform the Department when this has been done.
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Based on record review, the licensee did not comply with the section cited above because no copy of the letter to evict dated 3/7/2024 was sent to the licensing agency, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/04/2024
Section Cited
CCR
87507(g)(8)
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87507 Admission Agreements (g) Admission agreements shall specify the following: (8) General facility policies that are for the purpose of making it possible for residents to live together.

This requirement was not met as evidenced by:
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On or before the due date, the Licensee shall create the Resident Handbook that includes all of the policies toi fulfill this Title 22 regulation. The ED shall inform the Department when this has been done.
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Based on record review, the licensee did not comply with the section cited above because the Resident Handbook is missing from the Admissions Agreement as an Addendum and no copy was sent to the POA, which poses a potential health, safety or personal rights risk to persons in care.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3