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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005638
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:55:03 PM

Unfounded


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
03/17/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220317084208
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:
04/29/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sandhu Paramjit SinghTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident received care without a signed contract.
Facility does not properly document residents’ medication administration.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 11:30AM, Licensing Program Analyst's (LPAs) Jill Nakagawa and Chris Arnhold arrived at this facility unannounced to deliver findings for the above allegations. LPA's met with Administrator. Based on records reviewed, the allegation that resident did not have a signed contract is unfounded. A signed addmission agreement is on file. LPA's reviewed the medication documents and procedures of the facility. Facility uses pharmacy packaged blister packs that show dates medications are given and pharmacy provides a centrally stored medication list.

This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
03/17/2022 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220317084208

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:
04/29/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sandhu Paramjit SinghTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair.
Staff did not provide residents adequate supervision.
Staff did not give resident medication as prescribed.
Facility does not properly store residents’ medications.
Staff member did not provide a comfortable environment for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 11:30AM, Licensing Program Analyst's (LPAs) Jill Nakagawa and Chris Arnhold arrived at this facility unannounced to deliver findings for the above allegations. LPA's met with Administrator. Facility had a sewer issue that caused the lines to clog. Repairs were conducted and the lines fixed. Administrator provides supervision for residents and has another staff on call if needed. LPA's reviewed medication records and found medications were administered as prescribed. LPA's observed that medication is stored per regulation. Interviews conducted with residents did not show that the environment to be hostile. There were no accounts provided to support the allegation that staff did not provide a comfortable environment.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3