019200956-12-10-2025-15-AS-BFOG-DPGVZN-20251218155302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 12/10/2025
Date Signed: 12/10/2025 03:26:38 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
12/04/2025 and conducted by Evaluator David Doidge

COMPLAINT CONTROL NUMBER: 15-AS-20251204103845

FACILITY NAME:	ELDER ASHRAM		FACILITY NUMBER:	019200956
ADMINISTRATOR:	MARIA LOURDES V RIVERA		FACILITY TYPE:	740
ADDRESS:	3121 FRUITVALE AVE		TELEPHONE:	(510) 842-3192
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94602
CAPACITY:	90	CENSUS: 62	DATE:	12/10/2025
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Wellness Director Janelle Ubilas		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not ensure that resident received medical attention in a timely manner while in care.

Staff did not ensure that resident's nutritional needs were met while in care.

INVESTIGATION FINDINGS:

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On 12/10/2025 at 11:20 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegations above. LPA met with Wellness Director Janelle Ubilas and explained the purpose of the visit.

During the course of the investigation, LPA obtained copy of R1’s Physician’s Report (602), Admission Orders, Resident Appraisal, Elder Ashram Careplan for resident, correspondence between the facility and primary care provider, R1’s medication list, and an Unusual Incident Report with a letter to R1’s primary care provider. LPA also interviewed R1, S1, S2 and S3, and inspected the kitchen and food.

Allegation: Staff did not ensure that resident received medical attention in a timely manner while in care.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

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-20251204103845

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: 12/10/2025

NARRATIVE

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Continued from LIC9099

Investigation Findings: It was reported to the department that the facility did not timely respond to R1’s doctor for a potential UTI. LPA interviewed S2, who was on duty at the end of the day on Friday November 28th S2 reported that R1 informed staff that R1 felt symptoms of a urinary tract infection but not severe enough to need to go to the emergency room. R1’s primary care provider’s office is closed over the weekend. R1’s primary care provider was notified on Monday December first. The order for the urinary test and prescription for antibiotics came in on the first. The urine was collected on the second due to R1 not being able to provide enough urine when the test was available. LPA interviewed S3 who collected the urine sample. S3 reported to LPA that R1 had informed another med-tech that R1 had some discomfort, and mild symptoms of what R1 thought could be a urinary tract infection (UTI). S3 assessed R1’s symptoms. R1 had reported to S3 that R1’s symptoms were mild consisting of mild discomfort while urinating, but not a severe burning sensation. S3 reported no increase in confusion, agitation, nor other severe signs of a UTI being present for R1. R1’s primary physician was informed, and a urine sample and antibiotics were prescribed. S3 did the sample collection the day after the test was received due to R1 not having enough urine to fill the sample. S3 reported that R1 reported no discomfort nor burning sensation while providing the sample. S3 also reported there was no strong smell or other obvious signs of a severe UIT. A five (5) day supply of antibiotics was prescribed and received by the facility on Tuesday December second. Lab results for the urine test were not yet available. LPA interviewed R1. R1 did not recall the incident and stated that staff do respond to needs in a timely manner. As R1 had reported mild symptoms to staff with no urgency to see a health provider, and staff evaluations of R1’s symptoms and temperament were not above base line, staff did act in a timely manner in response to R1’s report of possible a UTI. Therefore, this allegation is unsubstantiated.

Allegation: Staff did not ensure that resident's nutritional needs were met while in care.

Continued on LIC9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20251204103845

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: 12/10/2025

NARRATIVE

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Continued from LIC9099-C

Investigation Findings: it was reported to the department that staff were encouraging balanced meals, however, W1 reported to the department that when R1 asked for a banana, R1 was offered flan instead. LPA interviewed R1. R1 did not recall the incident but reported to LPA that staff do not withhold snacks or meals and felt that staff do meet R1’s food needs. S1 reported that R1 has not been eating full meals as a way of getting R1’s family’s attention in hopes of being taken home. This was conveyed to R1’s primary care provider and responsible party. LPA interviewed S3 who reported that S3 will follow up with R1 in the late evening to ask if R1 would like something else to eat on days when R1 does not eat a full meal. S3 will provide a sandwich or other requested foods to R1 and ensures R1 is eating. S1, S2 and S3 reported that R1 had expressed depression like thoughts and a want to go home as a reason for not eating as much as before. Staff have been monitoring R1’s food intake and will follow up with R1 throughout the day and evenings to ensure R1 does eat enough. S1, S2 and S3 report that R1 prefers sweets, and asks specifically for sweets such as flan. Staff report trying their best to provide R1 with R1’s requests while encouraging R1 to eat more healthy options. S1 and S3 reported that staff do not withhold nutritional food from R1, and know what R1 prefers. If R1 were to ask for a specific food item, staff will offer an alternative that is readily available but will confirm with R1 if the alternative is acceptable. Staff never force residents to eat anything they do not want to eat. LPA toured kitchen and the facility has nutritional food options available. This allegation is therefore unsubstantiated.

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

No deficiencies cited.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

LIC9099 (FAS) - (06/04)

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