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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:34:14 PM

Unsubstantiated


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
05/03/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220503092703
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: 67DATE:
06/24/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Janelle Ubilas, Wellness DirectorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Neglect of Physical Care.
INVESTIGATION FINDINGS:
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On 6/24/22 at 3:45 p.m, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and delivered investigation findings. LPA explained the purpose of the visit with Wellness Director.

The Department has investigated this allegation and per records review and interviews found that both facility staff and outside agency staff provided ADL to resident R1. R1's care note documented that R1 refused ADL 2 days on 4/8/22 and 4/15/22. S1, S2 and S3 stated when resident refused ADL, staff took a couple attempts before reporting to responsible parties and documented it. R1’s responsible party W1 stated that R1’s ADL care mainly was provided by caregivers from an outside agency. Therefore, the caregiver who didn’t brush R1’s teeth well was not Elder Ashram’s staff member. The problem has been resolved by the outside agency promptly. W1 stated that facility informed refusal incidents happened each time so W1 was fully aware.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
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-20220503092703
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: 019200956
VISIT DATE: 06/24/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted and a copy of this report provided to Wellness Director.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2