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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:23:41 PM


Document Has Been Signed on 09/23/2022 02:23 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: 6DATE:
09/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Singh Sandhu Paramjit, Licensee/AdministratorTIME COMPLETED:
02:30 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived at 1:40 PM unannounced to do inspect the facility and check on the new residents. Facility is now at capacity.

Facility was clean and a comfortable temperature, despite being on a planned power outage by power company. Administrator was prepared in advance for that, and had a generator on line to run appliances, air conditioner, washer/dryer.

At the time of visit Administrator was attending a Zoom Conference regarding the arrival of new resident, and had another Zoom Conference planned for another resident later in the afternoon. Residents were all clean and appropriately dressed. 4 of the 6 residents were out in the living area interacting and socializing together. The other 2 residents were resting in bed, comfortably.

There were no deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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