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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:19:41 AM


Document Has Been Signed on 06/07/2022 11:19 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: 2DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Paramjit Singh Sandhu, AdministratorTIME COMPLETED:
11:20 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. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care of the Elderly Facility.

LPA observed a screening station at the entrance of facility which had hand sanitizer, a temperature sensor, and masks. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. LPA 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 residents.

LPA observed 2 residents in care; a new resident is possibly moving in shortly. The facility was clean and a comfortable temperature. N-95 respirator Fit testing completed. LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and , and hand sanitizer. 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, and is aware of the Infection Control Plan due to CCL by June 30, 2022.

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: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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