577005638-1-9-2025-21-AS-KMOA-DCYMVA-20250116085625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577005638
Report Date: 01/09/2025
Date Signed: 01/09/2025 10:25:38 AM

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
09/18/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240918153629

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: 6	DATE:	01/09/2025
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Administrator, Paramjit Singh Sandhu via phone and Shova Panta Caregiver		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff are not following resident's care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to complete an investigation and deliver findings regarding the above allegation. LPA requested documents, conducted interviews and made observations. LPA was met with Shova Panta at the facility. Administrator Paramjit Singh Sandhu was reached via phone to review the findings.

LPA conducted an interview with resident R1. R1 stated they were satisfied with their care and supervision of medications. LPA asked them if they received their medications. R1 stated that the Administrator assisted with the pain management medications. S1 helped with the administration of medications including morphine. At the time of the interview R1 was coherent and cognizant and seemed to be in good spirits. LPA asked if visitations were occurring and R1 said yes.

Continued on 9099....

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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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-20240918153629

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: 01/09/2025

NARRATIVE

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Continued from 9099....

LPA conducted interviews with outside parties who stated that R1 appeared to be satisfied at the facility with their care. LPA asked outside parties if S1 had ever failed to allow hospice staff access to the facility and was informed no and that hospice staff had always been allowed access to their patients.
LPA examined the medication records for R1 and found them to be in order. LPA was unable to examine the medications as they had been destroyed upon the passing of R1. MAR (Medication Administration Record) for R1 indicates that medications were administered as ordered. Refusals of medications are noted in the MAR.

Based on LPA interviews, there was no one who was able to state any act of physical threats were made by S1. In addition, LPA was unable to locate mandated reporting records to substantiate acts of violence in violation of Title 22 Regulations.

Based on the interviews conducted and the records reviewed, there was not evidence to meet the evidence standard therefore the allegation that staff are not following the resident’s care plan 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(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: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC9099 (FAS) - (06/04)

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