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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200956
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:16:25 PM

Document Has Been Signed on 08/26/2022 12:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 70DATE:
08/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Janelle Ubilas, Wellness DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/26/2022 at 10:40 a.m., Licensing Program Analysts (LPAs) C. Lin and J. Sampairconducted case management while conducting a complaint investigation, met with Wellness Director and explained the purpose of visit.

Upon entry, LPAs observed staff S1 walked from the hallway, spoke with residents and staff without wearing face mask. Approximately 30 minutes later, LPAs observe another staff S2 walked to the conference room where LPAs were didn't wear face mask. Facility had 2 positive Covid-19 cases for residents on 8/15/22 and are still under monitoring by CCL and Alameda Public Health.

Deficiency is cited per Title 22 California Code of Regulations. A repeated deficiency civil penalty $250 is assessed today.

Exit interview was conducted with Wellness Director, LIC809D, LIC421FC, Appeal Rights, and a copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/26/2022 12:16 PM - It Cannot Be Edited


Created By: Catherine Lin On 08/26/2022 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELDER ASHRAM
FACILITY NUMBER: 019200956

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall....(2) To be accorded safe, healthful....

This requirement is not met as evidenced by:
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The Wellness director agreed to train all staff regarding the importance of wearing mask, submit copy of training with staff signature to CCL by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above, two staff were observed not wearing face mask in the facility which poses an potential health, safety or personal rights risk to persons in care.
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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 Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
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