019200956-7-6-2021-15-AS-KHOS-C6FHHD-20210901061233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 07/06/2021
Date Signed: 07/06/2021 04:33:42 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
01/21/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210121161203

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: 60	DATE:	07/06/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Nader Shabahangi, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Facility not following COVID-19 safety procedures.

INVESTIGATION FINDINGS:

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On 7/6/2021 at 1:35 PM, Licensing Program Analysts (LPAs), L. Hall and G. Luk arrived unannounced to deliver complaint findings for the above allegation. LPAs met with Administrator, Nader Shabahangi and explained the reason for the visit.

During the course of the investigation, LPAs interviewed five (5) staff and two (2) residents, and toured the common areas and shared bathrooms. LPAs obtained a copy of the staff roster, resident roster, and a letter from the facility's LVN. Staff and residents that were interviewed all stated that a COVID-19 positive staff was not allowed to return to work until the quarantine period was over, facility had a red zone on the west wing dedicated for the positive residents, and designated staff was assigned to care for positive residents.

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 with Administrator and a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

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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