<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200956
Report Date: 07/16/2020
Date Signed: 07/16/2020 01:19:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELDER ASHRAMFACILITY NUMBER:
019200956
ADMINISTRATOR:SHABAHANGI, NADERFACILITY TYPE:
740
ADDRESS:3121 FRUITVALE AVETELEPHONE:
(510) 842-3192
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:90CENSUS: 70DATE:
07/16/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Ami Champaneri, Business PartnerTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs) J. Jackson and L. Francisco conducted a televisit pre-licensing inspection on this date starting at 10:25 am via facetime due to shelter in place directed by the Governor. LPAs met with Business Partner, Ami Champaneri. The facility's fire clearance was approved for all 72 non-ambulatory and 18 bed-written.

During the televisit inspection, LPAs toured facility with Ami including but not limited to the residents bedrooms, multiple activity room, dinning room, medication room, kitchen, and outdoor areas. Residents bedrooms are equipped with the proper furniture and bedding linens. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The kitchen was observed clean and within compliance. LPAs observed a one week supply of non-perishable and 2-day perishable foods. Refrigerator was maintained at 38 degrees. Freezer was maintained at 0 degrees. Bathrooms were equipped with grab bars and non-skid mats. Living room is equipped with the proper furniture for the residents. There is a designated storage for chemicals. Indoor and outdoor passageways were free of obstruction. LPAs observed fire extinguisher to be fully charged. LPA's advised Business Partner fire extinguisher is due for service. LPAs observed Smoke Detector, Carbon Monoxide detector, and sprinkler system were interconnected and observed through the facility. LPAs observed medications were locked in a medication room and first aid kit is complete. LPAs advised Business Partner was aware hot water temperature should be maintained between 105 degrees F and 120 degrees.

Component III has been waived. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Business Partner. LPAs will email a copy of report to Business Partner and Executive Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jasmine JacksonTELEPHONE: (510) 285-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1