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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200514
Report Date: 07/17/2020
Date Signed: 07/17/2020 04:56:02 PM



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
07/14/2020 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20200714154433
FACILITY NAME:ELDER ASHRAMFACILITY NUMBER:
019200514
ADMINISTRATOR:NADER R SHABAHANGIFACILITY TYPE:
740
ADDRESS:3121 FRUITVALE AVETELEPHONE:
(510) 842-3192
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:90CENSUS: 71DATE:
07/17/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Maria 'Malou' Rivera/Business Office ManagerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo called the facility in order to investigate the above allegation. LPA spoke with Maria 'Malou' Rivera/Business Office Manager. LPA explained that the reason for the call is to inform that a complaint has been received. LPA further explained that due to present shelter in place order and directive by management to telework, the notification and investigation are done via video conference.

LPA informed Ms. Rivera that it's alleged that resident (R1) was "dumped" to a homeless shelter on May 2020 via Lyft.

On this day, July 17, 2020, LPA requested Ms. Rivera to submit copies of resident rosters for May 2017, June 2017 and May 2020. LPA interviewed staff (S1) and Ms. Rivera. Ms. Rivera stated R1 was a resident in this facility from March 31, 2017 until May 8, 2017. R1 was only in the facility temporarily as respite. Staff (S1) indicated that she remembers R1's last name but not the first name and that R1 had been a resident several years ago as respite.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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-20200714154433
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: ELDER ASHRAM
FACILITY NUMBER: 019200514
VISIT DATE: 07/17/2020
NARRATIVE
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The information obtained from the staff interviewed were consistent with the resident rosters and with the information obtain from another individual (OW) who indicated R1 was a resident of a rehab facility from May 13, 2017 to May 22, 2020 prior to being transported to the shelter via Lyft.

Based on all the information obtained, the allegation is closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the complaint is dismissed.

Exit interview conducted and copy of this report provided via email to Ms. Rivera.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2