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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 07/23/2021
Date Signed: 07/23/2021 11:22:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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:ELDERVILLAFACILITY NUMBER:
577005638
ADMINISTRATOR:PARAMJIT SINGH SANDHUFACILITY TYPE:
740
ADDRESS:1301 HOMEWOOD DRIVETELEPHONE:
(530) 329-3834
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:6CENSUS: 4DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paramjit Singh Sandhu, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Jill Nakagawa and Licensing Program Manager (LPM) Kimberley Mota arrived unannounced to conduct an Annual Required inspection and met with Paramjit Singh Sandhu, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care of the Elderly Facility.

LPA and LPM observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and masks. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Administrator will begin documentation of visitor screenings and staff/resident temperatures and symptoms. Staff and clients' temperatures are taken 2 times day. LPA and LPM conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings.
Staff clean and disinfect the facility daily. High touched surface areas are disinfected. The facility has a designated visitation area, provides virtual visits and phone calls for family to stay in contact with clients.

LPA and LPM observed 4 clients in care. Facility staff have completed training on infection prevention, symptoms, transmission and PPE use. N-95 respirator Fit testing completed.
LPA and LPM observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. Staff wore a face mask during this visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services.

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: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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