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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200956
Report Date: 04/28/2026
Date Signed: 04/28/2026 02:52:28 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
04/10/2026 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20260410124939
FACILITY NAME:ELDER ASHRAMFACILITY NUMBER:
019200956
ADMINISTRATOR:MARIA LOURDES V RIVERAFACILITY TYPE:
740
ADDRESS:3121 FRUITVALE AVETELEPHONE:
(510) 842-3192
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:90CENSUS: 64DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Assistant Executive Director Janelle UbilasTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff interacts inappropriately with resident

Staff did not administer resident's medication
INVESTIGATION FINDINGS:
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On 04/28/2026 at 12:45 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to deliver findings in regards to the allegations above. LPA met with Assistant Executive Director Janelle Ubilas and explained the purpose of the visit.

During the course of the investigation, LPA obtained copies of the resident roster, staff roster and schedule, contact information for shift working NOC and PM shifts, Physician’s Reports, Appraisals Needs and Services, the Identification and Emergency sheets, and the Medication Administration Record (MAR) for four (4) residents. LPA also interviewed S1, S2 and S3, S5, as well as R1, R2 a, R3 and R4, in the facility. LPA also observed residents interacting with staff in common areas.

Allegation: Staff interacts inappropriately with resident

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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-20260410124939
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: 04/28/2026
NARRATIVE
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Continued from LIC9099

Investigation Findings: It was reported to the department that a staff on NOC shift has consistently been rude to a resident. This staff member is "very difficult" and "rude" to a resident in general. It was alleged that the staff member said 'with that attitude you get nothing' and threw pain meds in the garbage. LPA interviewed S1 and S5, both of whom have supervised S4, neither have ever had a complaint against S4. LPA interviewed R1 who said that one staff member in particular is “rude” and will withhold medications thus upsetting R1. R1 reported that staff can be pleasant at times but will get upset when R1 asks for certain medications. R1 said this is why one staff member in particular is rude, as R1 will constantly ask that staff member for R1’s over-the-counter medication and that staff member will flat out refuse to provide them. This will get R1 mad and R1 will voice R1’s opinion. LPA interviewed S4 who said R1 will wake up late at night and demand over-the-counter medications. When S4 explains that R1 can only have certain medications at certain times, R1 will get upset and argue. LPA spoke with S3 who confirmed R1’s behavior. S3 said R1 is usually pleasant and easy to work with, however when R1 wants certain medication at times R1 cannot have them, R1 will get upset and accuse staff of being mean. S1, S2, ad S5 all confirmed R1’s behavior. LPA tried to interview R1’s roommate R2, however R2 was highly medicated and currently non-verbal. LPA interviewed R3 and R4. Both residents are long term residents and reported never hearing or seeing staff being rude. Both R3 and R4 report NOC shift are friendly. LPA walked around facility and observed staff actively engaging with residents and having friendly conversations. Based on interviews conducted, the above allegation is UNSUBSTANTIATED.

Allegation: Staff did not administer resident's medication

Investigation Findings: It was reported to the department that a staff member threw pain meds in the garbage and would not give a resident requested medication. LPA interviewed R1 who said when R1 asked for over-the-counter medication for pain, the Med-Tech told R1 it was not time for them. R1 reminded the Med-Tech that R1 has a prescription for over-the-counter medication that can be taken for pain and asked for that. R1 said the Med-Tech then said, 'with that attitude you get nothing' and threw away R1’s medication. R1 insisted that S4 threw out R1’s medication. R1 said it was the same cup used to give R1 R1’s medications, and there was no way to confuse it. LPA interviewed the S4. S4 informed LPA that S4 was approached by R1 around 9 or 9:30 PM as S4 was in the Medication room doing inventory. S4 said an hour earlier S4 had given R1 R1’s prescribed medications and R1 asked for over-the-counter pain medication.

Continued on LIC9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260410124939
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: 04/28/2026
NARRATIVE
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Continued from LIC9099-C

LPA reviewed R1’s medication list and confirmed with R1’s Medication Administration Record (MAR) that R1 did receive a prescribed pain medication at 8PM and therefore could not have further medications for another two hours as it would over medicate R1 as indicated in the medication dosage. R1’s Medication Administration Record (MAR) showed R1’s medications had been administered appropriately with no miscounts or missed dosages. S4 informed LPA that S4 did through away empty medication cups as S4 was cleaning out the med room when R1 came in. Based on interviews conducted, the above allegation is UNSUBSTANTIATED.

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

No deficiencies were cited during this inspection.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3