<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803333
Report Date: 03/14/2023
Date Signed: 03/14/2023 09:33:08 AM


Document Has Been Signed on 03/14/2023 09:33 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, LESLIEFACILITY TYPE:
740
ADDRESS:1414 CAMBRIDGE STREETTELEPHONE:
(415) 892-7641
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 2DATE:
03/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Leslie Wilson, AdministratorTIME COMPLETED:
09:45 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 case management and met with Leslie Wilson, Administrator. The purpose of this case management inspection is to follow up on facilities annual inspection conducted 1/20/2023.

LPA conducted facilities annual inspection January 20,2023, Administrator was out of country and facility was given 4 technical assistance (TA's). LPA received required annual documents from Administrator on 3/1/2023 & 3/8/2023 providing requested updated CPR & First Aid training for staff. LPA is checking remaining TA's have been addressed and fixed.

Liability Insurance on file expired, Licenser agreed to provide updated Insurance by 5/8/2023 per regulation HSC 1569.605. LPA provided copy of regulation.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1