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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:11:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
08/17/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220817164040
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:
08/26/2022
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Janelle Ubilas, Wellness DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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unlawful eviction.
INVESTIGATION FINDINGS:
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On 8/26/22 at 9:10am, Licensing Program Analysts (LPAs) C. Lin and J. Sampair arrived unannounced an initial 10-day complaint visit to investigate the above allegation. LPAs met with the Wellness Director Jenelle Ubilas and informed her of the purpose of visit.

The Department has investigated this allegation and per records review and interviews found that facility issued two 30-day Notices to R1. The initial 30-day notice was issued on 8/12/22. LPAs observed that it was invalid because it did not have the effective date and specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons for eviction. Facility reissued an amended 30-day notice on 8/16/22. LPAs observed that it was also invalid because it was back dated as 8/12/22 and it too did not have specific facts to permit determination of place, witnesses, and circumstances concerning those reasons for eviction.

Continue LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 3
Control Number 15-AS-20220817164040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELDER ASHRAM
FACILITY NUMBER: 019200956
VISIT DATE: 08/26/2022
NARRATIVE
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Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated.

Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of correction were discussed with the Wellness Director,

Exit interview conducted. Appeal Rights, LIC9099D, and copy this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220817164040
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELDER ASHRAM
FACILITY NUMBER: 019200956
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
87224(d)
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87224 Eviction Procedures
(d)The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
This requirement is not met as evidenced by:
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Administrator agreed to withdraw the eviction immediately, and will submit a copy of 30-day notice includes specific facts to CCL by the POC due date.
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Based on interview and records review, the licensee did not comply with the section above when 30-day eviction was issued for R1 which posed a potential personal rights risk to person in care.
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Type B
09/09/2022
Section Cited
CCR
87224(d)(1)(A)
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87224 Eviction Procedures
(d)The licensee shall set forth in the notice...
(1)The notice to quit shall include...
(A)The effective date of the eviction.

This requirement is not met as evidenced by:
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Administrator agreed to withdraw the eviction immediately, and will submit a copy of 30-day notice includes "Effective Date" to CCL by the POC due date.
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Based on interview and records review, the licensee did not comply with the section above when 30-day eviction was issued for R1 which posed a potential personal rights risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3