019200514-6-11-2021-15-AS-KHOS-C48LPM-20210622085612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200514
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:43:41 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
06/04/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200604155758

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: 0	DATE:	06/11/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nader R. Shabahangi, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
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9

-Financial Abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this inspection with Administrator to deliver findings on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via phone conference.

It was alleged that on 5/16/20, R1 attempted to withdraw a large sum of money from his bank with the purpose of providing it to a struggling individual who potentially worked at the facility. Throughout the course of this investigation, LPA conducted interviews, made observations, and reviewed records related to the allegation. Based on the information gathered, there was not a substantial amount of evidence to support the allegation and no independent evidence or witnesses could be obtained to support that a staff member solicited money from R1.

Based on the investigation, although the allegation 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 allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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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