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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 05/12/2021
Date Signed: 05/14/2021 09:48:26 AM



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
05/11/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210511143407
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:
10:35 AM
MET WITH:Janelle Ubilas, Wellness CoordinatorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Facility is not allowing visitors inside the residents' rooms
INVESTIGATION FINDINGS:
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On 05/12/21 at 10:35AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a tele-visit to investigate above allegation and met with Wellness Coordinator (WC). Due to COVID-19 shelter in place order, WC was not physically available to sign this report.

During investigation, WC verbally confirmed to LPA that facility is not allowing visitors inside the residents' rooms because they did not get the updated COVID-19 visitation guideline update from CDC until 05/07/21. LPA observed facility visitation policy document dated 04/12/21 show no room visits allowed. LPA advised WC that the Provider Information Notice (PIN 21-17-ASC) issued on March19, 2021 provides updated visitation guidelines which allows indoor and in-room visitation at all times for all residents regardless of vaccination status of the resident or visitor. The preponderance of evidence has been met. Therefore, the allegation that facility is not allowing visitors inside the residents' rooms is substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.




Substantiated
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)
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Control Number 15-AS-20210511143407
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2021
Section Cited
CCR
87468.1(a)(11)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Wellness Coordinator/Administrator agreed to submit to CCLD on or before POC due date a self certified statement having read, understood updated visitation guidelines as stated in PIN 21-17-ASC and will communicate updated guidelines to staff, authorized representatives and residents.
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This requirement was not met as evidenced by facility not allowing visitors inside residents' rooms which posed a potential infringement on residents' personal rights.
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Facility will also post this PIN 21-17-ASC in a prominent place where residents can easily access it and distribute the PIN summary for residents and their representatives
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
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