019200956-3-29-2022-15-AS-KHOS-CKAQFD-20221017120745

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 03/29/2022
Date Signed: 03/29/2022 06:06:13 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-20210823154328

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: 66	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Ami CHampaneri, co-founder/back up administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Residents are forced to stay in their rooms
Facility does not post food menus
Facility does not provide a variety of foods
Staff unable to communicate with resident due to language barrier
Facility does not have enough staff to meet the residents' needs
Residents' meals are served cold
Staff engage in inappropriate interaction in front of residents

INVESTIGATION FINDINGS:

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On 3/29/2022, 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 the course of the investigation, LPAs obtained and reviewed documents, and interviewed staff. LPAs observed all residents are free to get out from their room, residents stated that they do not feel forced to stay in their room, they are can go out from their room whenever they want. Menu was observed to be posted at the dining area. LPAs observed staff serving freshly cooked food during lunch time. Residents also have variety of food during lunch and menu matches the food that was served. Based on interview with residents, staff can communicate with residents clearly and residents can understand staff whenever they are talking with residents. Residents stated that they do not remember observing any staff showing inappropriate interactions with each other.
...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: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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-20210823154328

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: 03/29/2022

NARRATIVE

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The Department has investigated these allegations and based upon LPAs' observations, interviews conducted, and records reviewed, the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is 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: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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