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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 09/16/2024
Date Signed: 09/16/2024 05:59:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/13/2024 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240913165153
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: 49DATE:
09/16/2024
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Douglas Blake, Interim-Executive Director TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff not administering medications to resident on multiple dates.
INVESTIGATION FINDINGS:
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On 09/16/2024 around 01:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and closed the complaint for the above allegation. LPA met with Douglas Blake, Interim-Executive Director (ED) and explained the purpose of the visit.

ALLEGATIONS:
Staff not administering medications to resident on multiple dates.
SUBSTANTIATED

During the course of the investigation and visit, LPA conducted interviews with Reporting Party (RP), ED, Staff (S1) LPA requested Resident (R1)’s file including, but not limited to the following documents: Current Personnel Report (LIC 500), UIR's, R1’s Physician’s Reports, Case Notes, Medication Administration Records, Centrally Stored Medication lists, and faxes.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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-20240913165153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/16/2024
NARRATIVE
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...continued from LIC9099.

For the allegation, Staff not administering medications to resident on multiple dates refers to dates 4/29/24, 7/4/24, 7/21/24, 7/26/24-7/29/24, 8/9/24, 8/20/24 for R1. Based on interviews with RP, ED and review of R1’s MD notification Form, Medication Administration Records and Centrally Stored Medication lists; the medications are inconsistent and there is not a clear legend to identify what the entries mean for each day entered. Licensee did not assure R1 received his/her prescribed medication on the noted dates.

Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights were provided to ED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240913165153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
87465(d)
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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...unable to communicate his/her symptoms clearly, facility staff designated by the licensee...
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ED to assure that trained staff are available to assist residents as needed with medications, document refusal date and time, follow physician’s orders, reconcile R1's medication list, perform staff training for all personnel that administers medication. Submit proof of procedures with names of attendees to CCLD by COB 09/19/24.
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assist the resident with self-administration...
-This requirement is not met as evidenced by:

Based on interviews and records reviewed, Licensee did not assure residents received administration of medication(s).
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3