019200956-3-18-2022-15-AS-KHOS-CDMJES-20220419065936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:58:24 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
01/25/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220125090022

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:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Janelle Ubilas, Wellness Director		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Resident is being physically abused while in care.
Resident sustained injuries while in care.
Staff are not assisting resident with bathing.

INVESTIGATION FINDINGS:

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On 3/18/22 at 11:30am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and delivered investigation findings. LPA explained the purpose of the visit with Wellness Director.

Allegation: Resident is being physically abused while in care - Unsubstantiated
The Department has investigated this allegation and per records review and interviews found that staff, W1 and W2 denied R3 was being physically abused. Resident had an unwitnessed fall on 12/10/21 and was sent to the hospital immediately instructed by W2, R3 returned to facility on the same day without medication changed. This indicent had been reported to all required parties at time manner. Other than that, W1, W2, and staff have not seen any bruises or injuries on R3’s body at subject time period. W2 confirmed that R3’s declining was expected.

Continue LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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-20220125090022

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: 03/18/2022

NARRATIVE

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Allegation: Resident sustained injuries while in care - Unsubstantiated

The Department has investigated this allegation and per records review and interviews, R3 has been identified at risk for falling by facility staff and W2. Facility has been working with W2 closely to prevent R3’s falling, alarmed seat on wheelchair and lowered bed to the lowest position were set in December 2021, R3 has not been falling after discharging from hospital.

Allegation: Staff are not assisting resident with bathing - Unsubstantiated

The Department has investigated this allegation and per records review and interviews, W1 and W2 confirmed that R3 was clean and in good hygiene condition each time when R3 was visited. 4 residents were randomly interviewed, they stated that shower time were always on schedule and assisted by staff. 5 residents’ family members were randomly interviewed, they stated that they have seen their loved ones were clean and well so far. The Wellness Director stated that some residents refused to take shower sometimes but would be convinced, most of time they would take it at a later time of the day.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiency cited. Exit interview conducted and a copy of this report provided to Wellness Director.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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