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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 05/12/2021
Date Signed: 05/12/2021 12:46:39 PM



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
02/19/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210219122357
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: 60DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Janelle Ubilas, Wellness CoordinatorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speak inappropriately in front of residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/12/21 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent tele-visit and met with Wellness Coordinator (WC) to deliver finding. LPA explained the reason for the tele-visit with WC. Due to COVID-19 shelter in place order, WC was not physically available to sign this report.

During investigation, LPA interviewed 3 staff (S1, S2, S3) and 3 residents (R1, R2, R3) who were high functioning and alert. Residents told LPA that staff treat them well and that they did not experience inappropriate comments made by staff in front of them. LPA observed staff made conflicting statements regarding inappropriate comments made in front of residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email to Wellness Coordinator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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
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
02/19/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210219122357

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: 60DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Janelle Ubilas, Wellness CoordinatorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is dirty
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/12/21 at 10:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent tele-visit to deliver findings. LPA met with Wellness Coordinator (WC) and explained the reason for the tele-visit. Due to COVID-19 shelter in place order, WC was not physically available to sign this report.

During investigation, LPA toured the facility inside & outside with WC on 02/19/21 and 05/12/21. Hallways, bathrooms, lobby, bedrooms, visitation room and common areas were observed free of debris, in good condition and as stated by WC, frequently cleaned & sanitized daily by staff. LPA observed facility to be clean and in good repair during tele-visit. Photos were taken of areas observed by LPA which show that facility was not dirty.

This department had investigated the complaint alleging that the facility is dirty. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed this complaint. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email to WC.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2