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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 02/08/2023
Date Signed: 02/08/2023 05:09:28 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
01/05/2023 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230105163140
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: 68DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nader Shabahangi, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not ensure that staff paperwork was completed.
INVESTIGATION FINDINGS:
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On 2/8/2023 at 1:30 pm, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and deliver investigation findings. LPA met with Administrator and explained the him the purpose of the visit.

Allegation: Facility staff did not ensure that staff paperwork was completed – Substantiated
The Department has investigated this allegation, per records review and interviews, and found that staff S1 was employed from September to December 2022, facility HR department was not aware that S1’s health screen was incomplete.

Based on information obtained, the preponderance of evidence is met, therefore the allegation is SUBSTANTIATED.

Continue on 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: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 5
Control Number 15-AS-20230105163140
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: 02/08/2023
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations and Health and Safety Code (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.

Deficiency and plan and proof of correction were discussed with Administrator. 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: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230105163140
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: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2023
Section Cited
CCR
87411(f)
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87411 Personnel Requirements – General
(f) All personnel…shall be in good health, and physically and mentally capable of performing assigned tasks…health screening…performed by a physician not more than six (6) months prior to or seven (7) days after employment…
This requirement is not met as evidenced by…
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Administrator agrees to review regulation and retrain staff, submit the in-service training to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed that facility was not aware that staff S1 who was employed from September to December 2022 didn’t complete health screening which poses/posed a potential health, safety or personal rights risk to persons 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: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/05/2023 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230105163140

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: 68DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nader Shabahangi, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff does not allow residents to practice religion and prevent residents from being in the front lobby of the facility.
Facility staff yell at resident.
Facility staff does not ensure effective communication between care providers.
Facility staff segregate residents to certain dining rooms.
Facility is in disrepair, staff does not maintain facility clean, sanitary, and free of odors, and facility has pests.
INVESTIGATION FINDINGS:
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On 2/8/2023 at 1:30 pm, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and deliver investigation findings. LPA met with Administrator and explained the him the purpose of the visit.

Allegation: Facility staff does not allow residents to practice religion and prevent residents from being in the front lobby of the facility – Unsubstantiated
The Department has investigated this allegation, per observations, interviews, and found, staff stated that residents have freedom to practice their religion. Staff stated that residents were not asked to leave lobby when there was tour, residents usually have group activities when tour was going on. During the course of investigation, Christmas decorations were observed in the lobby and hallway on 1/10/23. Pictures of Christmas party celebration was seen by LPA on 1/10/23. LPA observed that 3 residents sat in the lobby peacefully when a tour started at 1:30pm on 2/8/23.
Continue LIC9099-A-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230105163140
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: 02/08/2023
NARRATIVE
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Allegation: Facility staff yell at resident – Unsubstantiated
The Department has investigated this allegation, per interviews and found that staff yell at resident was not observed or witnessed by staff and residents who were interviewed.

Allegation: Facility staff does not ensure effective communication between care providers – Unsubstantiated
The Department has investigated this allegation, per record reviews and interviews, and found that each time when the communication devices (Walkie Talkie) were broken, Administrator had made affords to repair or replace them. Multiple receipts of repairing or replacing devices, and communication with vendors as proved documents were reviewed and obtained by the department.

Allegation: Facility staff segregate residents to certain dining rooms – Unsubstantiated
The Department has investigated this allegation, per interviews and found, staff stated that residents were assigned to dinning room where was close to where they lived. All residents were served the same meals except some residents have special diet. Staff stated that no discrimination was observed or witnessed.

Allegation: Facility is in disrepair, staff does not maintain facility clean, sanitary, and free of odors, and facility has pests – Unsubstantiated
The Department has investigated this allegation, per interviews and record reviews and found, staff stated that facility is clean in general, if something was broken, maintenance staff always fixed them in short period of time. Staff stated that janitors cleaned bathrooms and bedrooms daily. Facility has the contact with pet control company Xpedite Pest Elimination that inspected the facility monthly. The receipts of services from January 2022 to January 2023 as proved documents were reviewed and obtained by the department. During the course of the investigation, facility was observed in good sanitary condition and free of odors.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5