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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200514
Report Date: 08/20/2020
Date Signed: 08/20/2020 10:10:58 AM



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
05/21/2020 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200521103613
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:0CENSUS: 69DATE:
08/20/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Riveria, Business Office ManagerTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff failed to properly administer resident's medication while in care
Staff unlawfully evicted resident
INVESTIGATION FINDINGS:
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On 08/20/2020, Licensing Program Analyst (LPA) T. White called the facility to deliver the complaint findings for the above allegations. LPA spoke with Business Office Manager, Maria Rivera. LPA explained due to the present shelter in place order by the Governor, the notification of the complaint is being done over the phone.

During the course of investigation, LPA conducted interviews and collected documentation in relation to the complaint. Based on interviews and documents collected, facility attempted to administer medications to Resident #1 (R1). Facility contacted Hospice Agency regarding R1’s medications refusal. However, R1 continued to refuse medications.

Based on information collected, facility provided a valid 30-day eviction notice to R1. However, the eviction moratorium was placed on California.

Report Continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020
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-20200521103613
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: 08/20/2020
NARRATIVE
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Business Office Manager and a copy of report emailed to facility.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2