019200514-8-31-2020-15-AS-HHUL-BSZTWB-20200831150513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200514
Report Date: 08/31/2020
Date Signed: 08/31/2020 11:16:48 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
02/27/2020 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200227144939

FACILITY NAME:	ELDER ASHRAM		FACILITY NUMBER:	019200514
ADMINISTRATOR:	NADER R SHABAHANGI		FACILITY TYPE:	740
ADDRESS:	3121 FRUITVALE AVE		TELEPHONE:	(510) 842-3192
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94602
CAPACITY:	0	CENSUS: 69	DATE:	08/31/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Nader Shabahangi, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident left in a soiled diaper for a long period of time.
Staff did not provide resident with clean linen.
Facility shower does not deliver hot water.
Staff did not provide resident with towels.

INVESTIGATION FINDINGS:

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On 08/31/2020, Licensing Program Analyst (LPA) T. White called the facility to deliver the complaint findings for the above allegations. LPA spoke with Nader Shabahangi, Administrator. 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, the LPA conducted interviews and collected documentation in relation to the complaint. Based on interviews, 4 of 5 residents stated the facility does not leave their diapers for a long period of time. However, there is not enough evidence to prove or disprove the allegation.

Report continues on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200227144939

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: 08/31/2020

NARRATIVE

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This agency has investigated the complaint staff did not provide resident with clean linen. Based on interviews, 4 of 5 residents stated the facility provides clean linens. During inspection on 03/03/2020, LPA observed the facility had adequate supply of clean linens. However, there is not enough evidence to prove or disprove the allegation.

This agency has investigated the complaint facility shower does not deliver hot water. Based on interviews, 4 of 5 residents stated the facility provided hot water. Based on inspection on 03/03/2020, LPA observed the facility hot water was measured between 105- and 120-degrees F. However, S1 stated that on Wednesday February 26, 2020 the facilities water was shut off temporarily. S1 stated that the facility turned off the water for an hour in a half because the facility was installing a washer and dryer.

This agency has investigated the complaint staff did not provide resident with towels. Based on interviews, 3 of 5 residents stated the facility provides the residents with enough towels. Based on inspection visit, LPA observed an adequate supply of towels. However, 1 of 5 residents stated the facility needs more towels.

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 Administrator and a copy of report emailed to facility.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020

LIC9099 (FAS) - (06/04)

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