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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803333
Report Date:
05/31/2022
Date Signed:
06/01/2022 09:25:03 AM
Document Has Been Signed on
06/01/2022 09:25 AM
- 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:
SUNDANCE VILLA INC.
FACILITY NUMBER:
216803333
ADMINISTRATOR:
WILSON, LESLIE
FACILITY TYPE:
740
ADDRESS:
1414 CAMBRIDGE STREET
TELEPHONE:
(415) 892-7641
CITY:
NOVATO
STATE:
CA
ZIP CODE:
94947
CAPACITY:
4
CENSUS:
3
DATE:
05/31/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:15 PM
MET WITH:
Leslie Wilson - Licensee/Administrator
TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management - other and met with Administrator/Licensee Leslie Wilson. There are 3 residents with no resident under hospice at this time. Case management is being conducted in order to have Marin County Public Health Survey conducted.
MCPH survey has been submitted at this time.
There were no deficiencies cited at this time.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5040
LICENSING EVALUATOR NAME:
Carla Fernandes-Goes
TELEPHONE:
707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
05/31/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/31/2022
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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