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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:33:46 PM


Document Has Been Signed on 06/10/2024 02:33 PM - 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:
06/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:PARAMJIT SINGH SANDHU, Licensee/AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and found the facility to be clean and at a comfortable temperature. There was (1) one resident receiving hospice services and (5) five other residents receiving varying levels of care. All residents were clean, comfortable and well-groomed. The Administrator and (1) one caregiver on site.

Upon arrival, LPA noted that there was a great deal of heavy equipment in the area and road work being done in front of the facility. Licensee reported that he had talked with construction workers, to assure that he could leave facility when necessary/in an emergency.

At the time of visit several residents were in the living room watching television. LPA was treated to a recital by one of the residents. (3) three other residents were resting in their rooms.

LPA observed that the Licensee was doing some maintenance to the exterior of the facility, but walkways and back patio were clear and accessible. Licensee to inform LPA when maintenance and road construction are completed.

No deficiencies were found at the time of inspection.
No citations issued.

Exit interview conducted with Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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