216803333-1-20-2023-21-AS-SHAN-CN9PZ5-20230120104458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803333
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:45:17 AM

Document Has Been Signed on 01/20/2023 10:45 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:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Loida Montejo - Staff		TIME COMPLETED:	10:45 AM

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) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Loida Montejo. Administrator/Licensee Leslie Wilson was unavailable at today’s inspection. There are 3 residents, one in the hospital currently, one resident has dementia, and none on hospice at this time. During facility tour on 1/20/2023 with staff; facility was found to be at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/11/2022 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored and locked under the kitchen sink and garage. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Residents’ medications are stored and locked in the medication file cabinet by the kitchen although there was over the counter medications on top of cabinet and undisposed of medications in large Ziplock bag in garage (see LIC 9102) for technical assistance. Facility has a 30-day supply of medication for residents. Facility understands that disaster drills must be conducted at least quarterly and records should be available for the Department to review, staff informed LPA they have not conducted a drill in a year (see LIC 9102) for technical assistance. Infection Control: Facility has submitted a mitigation program plan and infection control plan. Posters have been placed throughout of the facility. Facility has hand sanitizer available; visitors and staff before coming into work and temperature is checked and logged. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 01/20/2023

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Facility has PPE supply stored in the kitchen and garage. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA was not presented with proof of current CPR & 1^st Aid certification for staff. One staff informed they need to renew and the other was unable to provide proof. (see LIC9102) for technical assistance.

Administrator Certificate is for Leslie D. Wilson # 6020174740 Exp. 5/7/2024
All staff have received COVID booster vaccinations and work exclusively at this facility

There were no deficiencies cited at this time.

Department is requesting facility to submit the following updated documents by 2/10/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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