019200956-3-7-2024-15-AS-YFLS-D46UAF-20240409152439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 03/07/2024
Date Signed: 03/07/2024 02:32:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/26/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240226103804

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: 65	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maria Loudes-Rivera, Associate Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not allow resident to have visitors
Staff do not allow resident to go out with family member

INVESTIGATION FINDINGS:

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

On 3/07/24 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Maria Loudes-Rivera, Associate Executive Director and explained the purpose of the visit.

During the course of the investigation LPA attempted to interview the reporting party (RP) but the RP’s phone was disconnected, and no email was provided. LPA interviewed S1 at the facility.

LPA reviewed R1’s file. R1 was admitted to the facility on 5/21/18 and moved out on 5/15/23. There were no notes in R1's file regarding the RP. The complaint provided no specifics as to when the allegations might have occurred. S1 stated that all family members are allowed to visit during regular visiting hours. The facility does not have a policy that excluded visitors.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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 2

Control Number 15-AS-20240226103804

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/07/2024

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
26
27
28
29
30
31
32

***report continues from LIC9099***

This agency has investigated the complaints alleging staff do not allow resident to have visitors and staff do not allow resident to go out with family member. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2