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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005638
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:32:40 PM

Substantiated


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 Jill Nakagawa
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:
06/07/2022
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Paramjit Singh SandhuTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff gave resident medications without a physician’s order.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced on this day for the purpose of investigating the above allegation and met with Administrator. LPA Nakagawa conducted a complaint investigation regarding the allegation listed above and findings were delivered during today's inspection. LPA conducted interviews, made observations, and record review during the investigation.
.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20220317084208
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: 06/07/2022
NARRATIVE
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(Continued from 9099)

The investigation revealed the following: Resident (R1) was administered the Over-the-Counter medication (topical lotion) by Licensee to relieve the resident's discomfort, however, upon review of the Medication List provided by both the Licensee and the hospice agency, this medication was not on the list of prescribed medications by the attending physician. Although Licensee thought they were acting in the interest of R1's comfort and request, there was no order for the Over-the-Counter medication.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20220317084208
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2022
Section Cited
CCR
87465(e)
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87465(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement is not met as evidenced by:
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LIcensee agrees to submit a plan to ensure residents in care will receive medications accompanied by a signed and dated written order from a physician. Correction plan will be submitted to CCL by 6/8/22.
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Based on LPA's observation and interviews and record review the LIcensee failed to receive a prescription for the Over-the-Counter Medication which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3