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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 05/07/2024
Date Signed: 05/08/2024 08:15:06 AM


Document Has Been Signed on 05/08/2024 08:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 6DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Paramjit Singh Sandhu, AdministratorTIME COMPLETED:
11:38 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Paramjit Singh Sandhu, Administrator.

LPA conducted a walk-through of the facility with Administrator and observed facility to be clean and well maintained and a comfortable temperature. Exterior walkways were clear of debris. Discussion was had with Administrator regarding removal and/or storage of extra equipment and building supplies currently outside.

At the time of inspection, there were 6 residents and the Administrator on site. Residents were clean and dressed appropriately. Residents' rooms were furnished per regulation, with personal touches added to make the facility homey. The facility has a visitation area and provides virtual visits and phone calls for family to stay in contact with residents. The fire extinguisher was last tested and charged on May 1, 2024. The smoke detectors and carbon monoxide detector system were operational, and are tested monthly. The last emergency drill was on March 3, 2024 and are done quarterly. Water temperature measured 114.4 F. There was an ample supply of perishable and non-perishable foods, as well as an emergency supply. Medications were stored and locked.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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