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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200956
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:25:34 PM


Document Has Been Signed on 02/23/2023 03:25 PM - It Cannot Be Edited

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: 68DATE:
02/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Nader Shabahangi, AdministratorTIME COMPLETED:
03:35 PM
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On 2/23/23 at 2:25 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit on this date to provide technical assistance.

LPA received a letter from the facility that stated they could no longer met the needs of R1. During the visit LPA interviewed Administrator and Wellness Director Janelle Ubilas. LPA also reviewed facility roster and found that R1 is listed on the roster

R1 was admitted to Alta Bates Summit Hospital in Berkeley on February 9.2023 and is currently still a patient at the hospital. R1's condition has deteriorated, and the facility has determined that they can no longer meet R1's needs. R1 was at the hospital for cataract procedure and subsequently suffered Congestive heart failure.

LPA advised Administrator to file a 30 day eviction letter to R1 to meet regulatory requirements and avoid an Unlawful Eviction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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