<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:10:47 PM


Document Has Been Signed on 07/27/2022 12:10 PM - 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: 4DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Paramjit Singh SandhuTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and check on the submission of the Infection Control Plan. Administrator Sandhu met LPA at the door, wearing a mask. There are 4 residents now. All residents are adjusting to each other well. The facility was clean and at a comfortable temperature. All plumbing issues from earlier in the year were completed and the walkway to the front door is in safe working order.

LPA sent Infection Control Plan information to Administrator to aid in his submission of plan.

There were no deficiencies found at the time of the inspection.
No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1