019200956-6-11-2021-15-AS-KHOS-C48M2X-20210622091416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:53:59 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
03/23/2021 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210323135129

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: 85	DATE:	06/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Nadar Shabahangi, Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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-Resident has unexplained weight loss.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this inspection with Administrator to deliver findings on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via phone conference.

It was alleged that R1 experienced severe weight loss in excess of 40 lbs in the span of less than a year due to unexplained reasons. During the course of the investigation, LPA reviewed R1's Weight Record, Physician's Report, Needs and Services Plan, Hospice Care Plan, Correspondence with Responsible Party, and other facility records pertaining to R1. Upon review of R1's weight record, R1's weight was recorded as 112 lbs on 2/24/20 and was consistently within 2-5 lbs each month thereafter and was recorded at 98.2 lbs on 3/11/21.

[See LIC9099-C for continued report].

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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-20210323135129

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: 06/11/2021

NARRATIVE

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In addition, LPA conducted 11 resident interviews, reviewed weight records and physicians reports for R2-R6, conducted 9 staff interviews, and reviewed Elder Ashram's The Art of Aging Cuisine Philosophy brochure and Snack and Smoothie menus.

LPA observed facility maintains a weight management program wherein staff monitor residents' weight as well as their food intake and consult with residents' physicians if any changes are observed and update resident care plans accordingly and as needed.

This agency has investigated the complaint allegation. 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 the complaint.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC9099 (FAS) - (06/04)

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