577005638-4-1-2021-21-AS-KMOA-BZVV8E-20210408161236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005638
Report Date: 02/16/2021
Date Signed: 04/01/2021 02:27:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2020 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201228141404

FACILITY NAME:	ELDERVILLA		FACILITY NUMBER:	577005638
ADMINISTRATOR:	PARAMJIT SINGH SANDHU		FACILITY TYPE:	740
ADDRESS:	1301 HOMEWOOD DRIVE		TELEPHONE:	(530) 329-3834
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	6	CENSUS:	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	04:55 PM
MET WITH:	Paramjit Sandhu		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff violated the rights of resident(s) in care

INVESTIGATION FINDINGS:

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On 2/16/2021 Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced tele-visit for the purpose of completing a complaint investigation regarding the allegation listed above. An additional visit was conducted for this complaint on 01/07/2021. LPA spoke with the Administrator, Paramjit Singh Sandhu. This reader is advised that this visit was made by phone due to COVID-19 precautions.

During the course of the investigation LPA Walters reviewed resident records, gathered documentation, interviewed residents, staff and various outside parties, reviewed police calls of service to the facility, conducted a virtual tour of the facility and made observations.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

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 21-AS-20201228141404

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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: ELDERVILLA	FACILITY NUMBER: 577005638
	VISIT DATE: 02/16/2021

NARRATIVE

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The complaint alleges that an incident occurred between staff (S1) and Resident (R1) resulting in S1 hitting R1. Based on interviews, observations and information gathered LPA learned that during the incident R1 became upset and combative with S1 at which time S1 attempted to de-escalate the situation and redirect R1. LPA was unable to prove or disprove that R1s rights were violated during the incident.

A finding that the complaint allegation of staff violated the rights of resident(s) in care is unsubstantiated, meaning that 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.

No deficiencies were cited. This report was emailed to facility to obtain signature.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021

LIC9099 (FAS) - (06/04)

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