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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 03/05/2025
Date Signed: 03/05/2025 02:34:59 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
10/17/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241017091349
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:
03/05/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janelle Ublias, Assistant Executive Director TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not treat resident with dignity or respect

Staff did not ensure that residents were accorded privacy while in the facility

Staff mismanaged resident medication

Staff did not provide adequate food service
INVESTIGATION FINDINGS:
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*Amended to remove double information*

On 3/5/2025, at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Janelle Ublias, Assistant Executive Director and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records.

Allegation: Staff did not treat resident with dignity or respect

During intake interview W1 stated there was anti-Semiticism from the staff. An

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20241017091349
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: 03/05/2025
NARRATIVE
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Continued from LIC9099.

example was the dining room tables were reserved and W1 was not allowed to sit there or would make W1 move. The six (6) staff that were interviewed all stated tables are not reserved. S1 and S4 stated there are residents that have their favorite seat, but it’s not reserved. The three (3) residents that were interviewed stated they sit wherever they please. One (1) resident have lived at the facility for several years and stated she has never observed a reserved table in the dining areas.

Allegation: Staff did not ensure that residents were accorded privacy while in the facility

W1 stated during interview that the shower room and none of the other rooms locked so anyone could walk in at any time. S3 stated the residents that do not require assistance with showering are able to lock the door, and the staff carries a key in case of an emergency. S6 stated the two showers, and both can lock, but has a key to open the door is necessary. S3 and S4 stated the showers are small but a resident and client can fit. S4 also stated staff try to give as much privacy as possible but it is hard with the rooms being shared rooms.

Allegation: Staff mismanaged resident medication

W1 stated during initial interview the staff often forgot to provide medication. S1 stated she had no knowledge of staff not providing medication, however, if this happened it would be reported to the appropriate parties. During record review of the medication administrative record (MAR) LPA did not observe any mismanaging of medication.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241017091349
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: 03/05/2025
NARRATIVE
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Continued from LIC9099C.

Allegation: Staff did not provide adequate food service

W1 stated the food is unhealthy but didn’t provide any details. S1 stated she was aware of sometimes resident wants something other than what was cooked, and the cooks would try to accommodate but they are not able to please everyone. R1 stated the cooks do not have a problem making something different if requested and they have the food items available. R2 and R3 stated the food is good and they are served enough. LPA toured kitchen and observed a variety of perishable and non-perishables for 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 and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3