<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200956
Report Date: 04/06/2021
Date Signed: 04/06/2021 06:35:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 62DATE:
04/06/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nader Shabahangi, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Praveen Singh conducted a Case Management health and safety inspection with Administrator in relation to the Department receiving a priority complaint.

During the inspection, LPA toured the facility, including but not limited to resident bedrooms, shower rooms, activity areas, dining rooms, kitchen, and outdoor areas. LPA observed there was a locked medication room for medications and cleaning supplies were kept locked in a closet. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed passageways appeared to be free of obstruction. LPA was informed by Administrator that everything was in good repair and no disruption to utilities.

At approximately 1:30 p.m., LPA observed R1's bed was partially blocked off by half-bed rails and the second half was blocked off by a night-stand, which restrained resident to the bed.

Deficiencies are cited per California Code of Regulations, Title 22, and begins on the next page. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted and a copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2021
Section Cited

1
2
3
4
5
6
7
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
8
9
10
11
12
13
14
This requirement is not met as evidenced by licensee's failure to ensure resident is able to move freely in and out of bed.

LPA observed R1's bed was blocked off by half-bed rails and a night-stand dresser which together blocked the entire length of the bed.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2