019200956-4-5-2022-15-AS-KHOS-CJW5CF-20221004195016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 04/05/2022
Date Signed: 04/05/2022 04:43:44 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
08/23/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210823152930

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: 67	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ami Champaneri, co-founder		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff have not returned all of the residents belongings
Resident room was dirty
Furniture was not appropriate
Resident was not being changed regularly
Food is not good quality
Resident lost a large amount of weight
Staff are unqualified to work with dementia residents
Staff did not report resident hospitalization's to the resident representative

INVESTIGATION FINDINGS:

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On 4/5/2022, Licensing Program Analysts (LPAs) L.Ibo and C. Lin arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Ami Champaneri, co-founder/back up administrator.

During course of investigation, R1's representative refused to sign form LIC621 or resident personal property and valuables which is a list of resident's valuables, however staff documented upon admission of R1 , R1 arrived with two sets of clothes, an ipad and phone and was returned to family on R1's discharge from the facility.
LPAs observed that facility was neat during visit, each residents room has the following furniture but not limited to; chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
LPAs reviewed and gathered staff dementia training records, based on the documents, staff completed all necessary trainings per tittle 22 regulation.
…Continued to LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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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Control Number 15-AS-20210823152930

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: 04/05/2022

NARRATIVE

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LPAs interviewed R1, based on the interview R1 did not like a lot of the food from the facility, and usually asked for alternative food like sandwiches. Based on 5/23/2021 Physician’s report, R1’s weight was 137lbs. however upon R1’s admission at facility, staff conducted their own assessment and R1's weight was 131.4lbs.

Based on records review R1 was able to care for his own toileting needs, able to bathe himself and able to dress or groom.

Based on interview and records review, staff reported to R1’s representative all hospitalization or any incident reports.

The Department has investigated these allegations and based upon LPAs' observations, interviews conducted, and records reviewed, the allegations are found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation has occurred.

Exit interview conducted with Ami Champaneri and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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