019200956-12-16-2022-15-AS-KHOS-CMJQC4-20221228110232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 12/16/2022
Date Signed: 12/16/2022 03:47:33 PM

Unsubstantiated

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
07/22/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220722155638

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: 70	DATE:	12/16/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	John Paul Roddy, Wellness Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to supervise resident in care which resulted to hospitalization

INVESTIGATION FINDINGS:

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

On 12/16/22 at 3:30pm, 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 the Wellness Director.

The Department has investigated this allegation and per records review and interviews found that staff noticed resident R1 didn’t feel well in outside area after exposure in sun for a long period of time. Staff treated resident cold water and activated 911 call immediately on 7/18/22. No witness or additional information indicated that lack of care and supervision was observed during the cause of investigation.

Although the allegation may have happened or are 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 the Wellness Director.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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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