Northwest Villa

Allegation investigated: Resident was injured by staff Resident financially exploited by staff Staff do not respond to resident's call for assistance in a timely manner

On /1025/2025, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to conduct additional interviews and deliver findings. LPA introduced self and stated purpose of visit, and allowed entrance by caregiver. LPA met with Administrator, Shailesh "Steve" Patel to conduct complaint visit. During the subsequent visit, LPA conducted interview and delivered findings. During the course of the investigation, facility was toured, records reviewed, and interviews conducted. This department had insufficient information regarding the allegations listed above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or disprove that the allegation occurred therefore the allegation is UNSUBSTANTIATED. No deficiencies issued during this complaint visit . Exit interview conducted. A copy of this report was provided to Administrator for facility records Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2025 · control 24-AS-20250805112857

Type of visit: Required - 1 Year

On 10/02/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct required Annual visit. LPA introduced self, stated the purpose of the visit, and was greeted by staff (S1) Mansi Mansi. Administrator (A1) Shailesh "Steve" Patel arrived shortly during inspection. LPA toured facility with A1. Five residents were present during inspection. One resident left during inspection with family. Licensee Rajat Roychoudhury arrives shortly during inspection and left facility shortly. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. LPA and S1 observed R3 walking in and using staff bathroom. Medications observed kept locked in kitchen shelf and in laundry room shelf. Medications were checked. Centrally stored medications list and MARs were reviewed. At approximately 09:19AM, LPA and A1 observed cleaning solutions stored under kitchen sink unlock. Fire extinguisher was observed in the kitchen cabinet with last serviced date of 09/11/25. A1 stated last fire drill completed on 02/2025. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature maintained at 37 degrees F and freezer temperature at -17 degrees C. Chemicals observed locked in laundry shelf. At approximately 10:20AM, chemicals were observed stored unlock under laundry counter. Lic 809 continues All bathrooms were toured. At approximately 10:26AM, LPA and A1 observed multiple medications under the staff bathroom sink. Under the staff bathroom sink was observed in disrepair. All bedrooms were observed to have the required furnishings and adequate lighting. At approximately 10:32AM, a chemical bottle was observed in room 1 bathroom shelf unlocked. Hot water temperature was tested maintained at 109.8 degrees F in bathroom 1, 107.1 degrees F in room 3 bathroom, 96.4 degrees F in room 4 bathroom, and 112.6 degrees F in bathroom 2. Toilet observed functional. Extra linens and towels were observed in hall closet. R1 was observed lying in bed with full rail. Room 4 was observed with half rail bed. Outside of the facility toured and observed to be free of debris. The side gate observed self-closing and self-latching. Adequate outdoor seating observed for residents. At approximately 10:44AM, LPA and A1 observed multiple paint cans and a gardening tool stored unlock in outside storage. At 12:36PM, LPA and A1 observed a hole on the wall by the front door. All residents and staff files reviewed. Smoke detectors and carbon monoxide observed operational during inspection. A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6 see attached 809D. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 10/08/25. Forms requested: Lic 308, Lic 500, Lic 610E, Lic 9020, current administrator certificate, and current liability insurance. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management. LPA was granted entry in to the facility by Staff Mansi Mansi. Staff contacted Administrator Shailesh "Steve" Patel who responded to the facility to assist with the visit. LPA toured the facility. LPA observed safety locks on exit doors. LPA observed cleaning supplies to be unlocked with child safety lock on the cabinet. LPA observed medications in a resident room accessible to all residents. LPA reviewed resident records. Hospice care plan was created when resident resided at another location. Care plan states caregiver will provide wound care. Items were blocking doors/pathways. LPA took photos. Deficiencies will be issued at a later date. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2025

Type of visit: Office

On this date, an Informal Office Meeting was conducted at the Regional Office with the Administrator and Licensee to address concerns regarding facility operations. Present during the meeting were: See Moua, Licensing Program Manager I Alexandria Walton, Licensing Program Manager I Mary Garza, Licensing Program Analyst Licensee, Rajat Roychoudhury Administrator, Minakshi Roychoudhury Administrator, Shailesh Patel The following were discussed and explained: - Compliance does not mean just completing POCs after the Department issue citations. The facility should aim and be proactive in making sure its operation meets Title 22 regulations. The Department is transparent that the regulations and CARE Tools are available. - The Licensee has declined TSP services. TSP is not mandatory. By declining, the licensee communicates that it can be compliant. Although the LPA has a consultative role, the Administrator by maintain an active certificate, understand all the laws, regulations, and Title 22 to operate. - Clearing Proof of Corrections – Clearing the POC is the responsibility of the LPA. The LPA was there during the inspection. The facility should communicate with the LPA when there are questions regarding the POC. - Administrative Actions - Continued non-compliance means the Department may take Administrative Action. This includes any of the following: revocation of the licensee, exclusion of staff, Administrator certificate de-cert, etc. The inimical conduct of any staff, administrator and licensee, including false statements to the LPA or Department, falsifying records and jeopardizing the health and safety of the residents, may result in Administrative Actions. - ALW Program and Hospice – residents being in the ALW Program, on Hospice, or Home Health does not negate the facility and its staff of the responsibility for providing care and supervision.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Staff did not address inappropriate interaction between residents in care Staff did not seek medical attention for residents in a timely manner Staff do not maintain a comfortable temperature in the home Staff do not provide adequate food service Administrator does not spend a sufficient amount of time managing the daily operations of the facility Facility is in disrepair

On 12/19/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to deliver findings on the above allegations. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Minakshi Roychoudhury. During the course of the investigation, LPA conducted interviews, reviewed records and conducted a facility tour. During the tour, LPA observed the facility to be clean, at comfortable temperature and in good repair. LPA observed an adequate food supply. Record review and interviews revealed that staff seek medical attention for residents. Interviews revealed that the Administrator spends a sufficient amount of time to managing the facility. Based on observation, interviews, and records review, the allegations: Staff did not address inappropriate interaction between residents in care; Staff did not seek medical attention for residents in a timely manner; Staff do not maintain a comfortable temperature in the home; Staff do not provide adequate food service; Administrator does not spend a sufficient amount of time managing the daily operations of the facility; Facility is in disrepair are UNSUBSTANTIATED. CONTINUED TO 9099C Unsubstantiated Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies issued. Exit interview conducted. A copy of this report was discussed and provided to Administrator, Minakshi Roychoudhury, whose signature confirms receipt of this document.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 24-AS-20241108113724

Type of visit: Case Management - Deficiencies

On 12/19/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management – deficiencies inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Minakshi Roychoudhury. The purpose of this visit is to issue citations found during the investigation complaint #20241108113724. Upon review of medications, LPA found multiple medications belonging to resident who no longer resides in the facility that were not destroyed or given to the responsible party. LPA also observed multiple over-the-counter medications stored in the facility and administered when needed. The facility was unable to provide a copy of the prescription and/or physician's order during the inspection. Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Minakshi Roychoudhury, whose signature on this form confirms receipt of this document. During the exit interview, LPA discussed moving the complaint poster to the entrance of the facility as required in Title 22 regulations, updating the LIC500 to include the times when the Administrator will be at the facility, and speak with staff to ensure staff are meeting the care and supervision requirements for all residents in care by knowing where/when residents have appointments or their day program schedules.the state’s words, verbatim · CDSS document, Dec 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i) · Plan of correction due date: Dec 20, 2024

87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy… shall be destroyed…by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years… this requirement was not met as evidenced by: Based on observation, the Licensee did not comply with section 87465 when medication belonging to a resident who no longer resides in the facility, was observed co-mingled with current resident medication, which is an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee agrees to write a written statement detailing the steps the facility will take to ensure the requirements of section 87465 are met to the Fresno CCL office. The statement should include the facility’s plan to review and train staff on section 87465. The plan should include a timeframe of when the training will be completed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(5)(A) · Plan of correction due date: Dec 20, 2024

(a) (5) Facility staff… may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician… this requirement was not met as evidenced by: Based on observation and record review, the licensee did not comply with section 87465 when over-the-counter medication was observed stored in the facility and administered without a prescription from a physician.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: Licensee agrees to submit a written statement detailing if the facility will remove the over-the-counter medication or obtain a physician’s order for the over-the-counter medication. The statement should include the facility’s plan to not administer any medication or supplements without a physician’s order.

Type of visit: Required - 1 Year

On 09/17/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator/Licensee via telephone, LPA met with Licensee, Rajat Choudhury.. LPA reviewed resident and staff files. LPA found that 3 out of 6 residents did not have a needs and services plan on file. Staff files were not complete. LPA did not observe documentation for staff training on file. LPA conducted a facility tour with the Licensee. All passageways were clear from obstructions. Facility appeared to be clean and odor free. Common areas observed to be furnished with adequate lighting. Resident bedrooms were toured. LPA observed safety door knob covers and door reinforcement locks installed on two exit doors. Licensee removed the safety locks during the inspection. Bedrooms were observed to have required furnishings. Bathrooms toured and observed to be operational. Hot water measured at 109.2 degrees F and 113.2 degrees F. LPA observed a bottle of comet under the sink in the bathroom, accessible to residents in care, Licensee removed the disinfectant and placed it in a locked cabinet in the laundry room. Food supply was checked. LPA observed an adequate supply of perishable foods and non-perishable foods. Cleaning supplies is kept in the laundry room. Medications checked and observed to be administered as prescribed. Fire extinguisher was last serviced on 04/10/2023. Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed with Licensee. A copy of this report and appeal rights were discussed and provided to Administrator, Shailesh Patel, whose signature on this form confirms receipt of this document. LPA is requesting the following documents be submitted to the Fresno CCL office by 10/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bondthe state’s words, verbatim · CDSS document, Sep 17, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.