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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201143
Report Date: 08/15/2023
Date Signed: 08/15/2023 05:23:14 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
05/23/2023 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230523165106
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: 48DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Mary Anne Watral, Interim-Executive Director (ED)TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Allegation: Facility is in disrepair
INVESTIGATION FINDINGS:
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On 08/15/23 around 01:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the findings for the above allegations. LPA met with Mary Anne Watral, Interim-Executive Director (ED) and explained the purpose of the visit.

Allegation: Facility is in disrepair

During the course of the investigation and visits, LPA and ED toured the facility, and LPA conducted interviews with ADM, S1, R1, W1 and W2. LPA requested R1's file including, but not limited to the following documents:

Personnel Report (LIC 500) & Resident Roster, current Physician’s Reports, After Visit Summaries, Care/Case Notes, Medication Administration Records (MAR), and Centrally Stored Medication lists for 04/2023 - 05/2023, and pest control agreement and reports for 04/2023 - 05/2023, emails, faxes, call logs and/or any other correspondences with R1's Primary Care Physician (PCP) and pharmacist for 04/2023 - 05/2023.

Interviews with Resident #1 (R1), Witness #1 (W1), and Witness #2 (W2) revealed that R1’s appliances would work at intermittent times on or before 05/25/23. W1 state that two refrigerators were damaged, and food had spoiled. R1 and W2 stated that R1 could only plug-in one appliance at a time.

At 02:50 PM, LPA, R1 and W1 witnessed the microwave stop working. The display went completely blank and there wasn’t any power to the microwave.

Around 03:30 PM, LPA notified the Administrator (ADM) of the power outage. ADM said that he/she thought the electrical problem in R1’s kitchen had been resolved. ADM requested that the maintenance department inspect R1’s kitchen electrical outlets in unit #321.

Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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

Exit interview conducted. A copy of this report and appeal rights provided to ED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4
Control Number 15-AS-20230523165106
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
87307(d)(2)
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87307 Personal Accommodations and Services...safety provisions shall apply to all facilities:
(2) The premises shall be maintained in...good repair...
-This requirement is not met as evidenced by:


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Licensee to inspect and make arrangements to repair to the kitchen electrical outlet on or before POC date and provide proof to CCLD.
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Based on observation and interviews, the licensee did not comply with the section cited above by the kitchen electrical outlet being in disrepair which poses a potential health and 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/23/2023 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230523165106

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: 48DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Mary Anne Watral, Interim-Executive Director (ED)TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed by physician
Staff did not keep facility free of pests
Staff left resident unattended
INVESTIGATION FINDINGS:
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On 08/15/23 around 05:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the findings for the above allegations. LPA met with Mary Anne Watral, Interim-Executive Director (ED) and explained the purpose of the visit.

During the course of the investigation and visits, LPA and ADM toured the facility, and LPA conducted interviews with ADM, S1, R1, W1 and W2. LPA requested R1's file including, but not limited to the following documents: LPA requested that R1's MAR be confirmed with PCP and R1’s Responsible Party (RP).

Continued on LIC 9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20230523165106
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: 08/15/2023
NARRATIVE
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...continued from LIC 9099

For the allegation, staff did not dispense medication as prescribed by physician:
Although R1’s physician’s report for 09/02/22 notes that R1 is unable to dispense his/her own medication, however, R1 does not have any cognitive impairment and visits the physician on his/her own. On 05/02/23, an unknown staff found R1’s medication in R1’s apartment. Upon receipt of the prescribed medication, the Nurse’s station sent medical notification to R1’s medical provider at Journey Meadows (JM) requesting an order to administer medication. The facility received confirmation from JM on 05/10/23, and began administering R1’s medication in question on 05/11/23.

For the allegation, staff did not keep facility free of pests:
The facility’s pest control contract is annual and began 06/2022, the last two inspections on 03/10/23 to and 04/07/23 both included interior and exterior areas to target ants to mitigate the spread. ADM confirmed that there are not any complaints of pest and R1 stated that he/she does not have any kind of pest issues.

For the allegation, staff left resident unattended:
S1 stated that the front desk is always attended around 8:00 AM and R1 stated, “I can make the determination if I want to go outside or not. Sometimes I will wait inside while I’m looking out. I’ll see them (Journey). Sometimes I just want to be outside. They let me out at the garage if the curb is too high or someone is parked in front.”

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview and a copy of this report and appeal rights provided to ED.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4