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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200956
Report Date: 12/08/2023
Date Signed: 12/08/2023 12:52:17 PM


Document Has Been Signed on 12/08/2023 12:52 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
E BAY DELTA AC/SC, 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: 65DATE:
12/08/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria Rivera, Associate Executive DirectorTIME COMPLETED:
12:30 PM
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On 12/08/2023 at 12:30pm, Licensing Program Analyst (LPA), L. Alexander arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPA met with Maria Rivera, Associate Executive Director and explained the reason for the visit.

Upon arrival, LPA observed total of two (2) residents sitting down in the common area, and one (1) staff sitting down at the front desk.

During the health and safety check, LPA toured the building including but not limited to common areas, bathrooms, bedrooms and outdoor area. Facility is noted to be clean and in good repair and clients in care appear to be safe. There are no imminent health/safety concerns on today's date.

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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