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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 03/12/2025
Date Signed: 04/07/2025 02:09:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/06/2025 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20250306160421
FACILITY NAME:ELDER ASHRAMFACILITY NUMBER:
019200956
ADMINISTRATOR:MEESHIA MARY T SANTOSFACILITY TYPE:
740
ADDRESS:3121 FRUITVALE AVETELEPHONE:
(510) 842-3192
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:90CENSUS: 61DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Interim Administrator Janelle UbilasTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility is violating resident’s personal rights

Staff do not ensure the residents intaking an appropriate amount of liquid
INVESTIGATION FINDINGS:
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On 03/12/2025 at 09:10 AM, Licensing Program Analysts (LPAs), D. Doidge and J. Clancy-Czuleger conducted an unannounced visit to open a complaint. LPAs met with Interim Administrator Janelle Ubilas and explained the nature of the visit.

During the visit, LPAs reviewed and obtained records for three (3) residents, including appraisal needs and services, physician's report, other medical information, and internal incident reports from February 22nd to March 11th. LPAs interviewed residents, staff and witnesses.

Allegation: Facility is violating the resident's personal rights

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 2
Control Number 15-AS-20250306160421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELDER ASHRAM
FACILITY NUMBER: 019200956
VISIT DATE: 03/12/2025
NARRATIVE
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Continued from LIC9099

Findings: Based on interviews it was found that R1 was receiving additional care from an outside individual that was paid for and chosen by the family. The facility informed the family of concerns and recommended an agency for more contestant care.

LPAs were informed that the personal caregiver was not associated to the facility nor a home health agency. Furthermore the facility confirmed that the care provider would not walk around the facility and would only stay in the resident's room. This individual did not have any contact with any other resident, was never caught sleeping during shift, and was very professional with staff. Staff was informed by the care provider if the resident required any assistance. The care provider was more of an overnight companion than health care provider.

Allegation of: Staff did not enure residents were in taking an appropriate amount of liquids
Findings: Based on interviews and observations the facility has hydration stations located throughout the facility and staff regularly remind residents to drink water and observe them for signs of dehydration.

Upon observation and interview, LPAs found that there were no violations of personal rights and that residents were appropriately hydrated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations above do not meet Regulation Requirements are un-substantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
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