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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 02/09/2021
Date Signed: 02/11/2021 03:37:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ELDERVILLAFACILITY NUMBER:
577005638
ADMINISTRATOR:PARAMJIT SINGH SANDHUFACILITY TYPE:
740
ADDRESS:1301 HOMEWOOD DRIVETELEPHONE:
(530) 329-3834
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:6CENSUS: 5DATE:
02/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Paramjit Singh SandhuTIME COMPLETED:
07:16 PM
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Licensing Program Analyst (LPA) Katrina Walters conducted a case management – incident visit today and met with Licensee, Paramjit Singh Sandhu. Regional Office received a report from Woodland PD of an incident that occurred at the facility on 2/9/21. LPA conducted a site visit to verify the health and safety of residents in care. LPA observed the following; staff was on-site at facility, food on hand to meet the regulations, utilities were in working order, toxins were secured, buildings and grounds were in good repair.

Interviews were conducted with residents and staff.
LPA requested the following documents for R1: a plan regarding R1's exit from facility, copy of incident report, admission agreement, physician report, identification page and needs and service plan, to be submitted to Community Care Licensing (CCL) Rohnert Park office, attention Katrina Walters by COB 2/10/21.

No citations are being issued today.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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