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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803333
Report Date: 11/10/2020
Date Signed: 11/16/2020 05:27:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SUNDANCE VILLA INC.FACILITY NUMBER:
216803333
ADMINISTRATOR:WILSON, LESLIEFACILITY TYPE:
740
ADDRESS:1414 CAMBRIDGE STREETTELEPHONE:
(415) 892-7641
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 1DATE:
11/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Leslie Wilson - Licensee/AdministratorTIME COMPLETED:
02:08 PM
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Licensing Program Analyst (LPA) C. Fernandes-Goes & LPA Sarangi contacted facility for an announced tele-visit with Leslie Wilson - Licensee/Administrator, for the purpose of a case management visit - health & safety check and to obtain additional information requested during a Welfare COVID-19 Check on 10/8/2020. LPAs toured the facility in a virtual tele-visit.

As per facility licensee Leslie, facility has only one resident at this time and resident has a diagnostic of dementia. Facility doesn't have a Dementia Program Plan for this facility which was requested during Welfare COVID-19 check and plan was due on 11/7/2020.
During virtual tele-visit, LPAs observed that facility has all postings required as per the Department guidelines; hand sanitizer, sign in, and thermometer to check visitors at facility entrance. Facility staff has been tested in the month of October and will be retesting on Friday 11/13/2020 - all results from October were negative. Licensee stated that staff has had all PPE training. Regarding facility admission of a dementia resident without a Facility Program Plan for Dementia, LPAs observed that facility exits have no auditory devices with exception of one that was off; knives were inside of a unlocked draw with a child safety device; toxins were unlocked; and medications were observed locked during this visit.

Department is requesting LIC 602 and appropriated needs & care plan for resident in care by 11/13/2020.
In addition, the following has been requested during Welfare COVID-19 call due on 11/7/2020 which has not been received by the Department as off 11/10/2020 and will need to be submitted by 11/13/2020:

· LIC 500 (attached) Personnel Report
· LIC 9020 (attached) Register of Facility Residents
· LIC 610ES – please review PIN 20-28 (attached) before completing this form
· & LIC 610 Emergency & Disaster Preparedness

This report is being conducted by phone due to COVD - 19 precautions.

No deficiencies cited during todays inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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