019200956-11-30-2020-15-AS-KHOS-BVWMLK-20201202084228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 11/25/2020
Date Signed: 11/30/2020 09:28:31 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
07/27/2020 and conducted by Evaluator Rolanda Pitcher

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200727131307

FACILITY NAME:	ELDER ASHRAM		FACILITY NUMBER:	019200956
ADMINISTRATOR:	SHABAHANGI, NADER		FACILITY TYPE:	740
ADDRESS:	3121 FRUITVALE AVE		TELEPHONE:	(510) 842-3192
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94602
CAPACITY:	90	CENSUS: 72	DATE:	11/25/2020
		UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Nader Shabahangi		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff make comments that are sexual in nature to female residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/25/20, Licensing Program Analyst, (LPA) Rolanda Pitcher conducted tele-visit by telephone with S1 to deliver complaint findings due to the Governor's COVID - 19 shelter-in-place order.

During the course of this investigation interviews were conducted with Staff; S1, S2, S3. S4,S5,S6. Based on this investigation LPA was not able to establish whether the allege incident happened due to the information and contact number could not be confirmed.

Although the allegation may have happened or are 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 with Nader Shabahangi

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE:

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

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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