577005638-8-13-2024-21-AS-KMOA-D9AMTZ-20240920095423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005638
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:12:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2024 and conducted by Evaluator Jill Nakagawa

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240724134346

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: 5	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Paramjit Singh Sandhu, Administrator		TIME COMPLETED:	03:14 PM

ALLEGATION(S):

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Personal Rights
Facility in violation of fire clearance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived unannounced on 08/13/2024 to conclude investigation and deliver findings on the above allegations. LPA met with Administrator, Paramjit Sandhu.

The complaint alleges that Personal Rights were violated due to Staff (S1) not allowing privacy during outside visitors visiting with resident (R1). LPA Nakagawa conducted interviews and made observations. It was reported that during a visit on 7/5/2024 R1 and visitor (V1) were not allowed the right to privacy. S1 stated “that R1 had lots of visitors and there had only been one incident where S1 felt it necessary to intervene on behalf of R1 as R1 had shared to S1 and R2 that R1 did not want visitors at that time."
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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-20240724134346

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELDERVILLA	FACILITY NUMBER: 577005638
	VISIT DATE: 08/13/2024

NARRATIVE

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Continued from 9099.....

Statements made by 2 of 3 individuals state R1 and the visitor (V1) were afforded a visit in private, but requested by S1 to be brief due to R1 being tired and the visit occurring after visiting hours. A short time later S1 requested that visitor (V1) leave and return during regular visiting hours. Based on LPA’s interviews the allegation that R1's Personal Rights were violated are unsubstantiated, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

In addition, Licensing Program Analyst (LPA) Nakagawa also concluded the investigation and deliver findings on the allegation that Facility is in violation of fire clearance. LPA met with Administrator, Paramjit Sandhu.

LPA Nakagawa reviewed documents, conducted interviews and made observations. The complaint alleges that the facility does not have a fire clearance for bedridden residents and believed that Resident (R1) was bedridden at the time of admission prior to the hospice placement. Review of admission agreement indicates R1 was admitted to the facility on 03/02/2024. The Physician’s Report dated on 03/01/2024 indicates that R1 was not bedridden nor were they bedbound prior to R1 beginning hospice care on 6/17/2024, therefore the allegation that Facility in violation of fire clearance is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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