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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803333
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:04:28 PM

Document Has Been Signed on 02/21/2025 03:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUNDANCE VILLA INC.FACILITY NUMBER:
216803333
ADMINISTRATOR/
DIRECTOR:
WILSON, LESLIEFACILITY TYPE:
740
ADDRESS:1414 CAMBRIDGE STREETTELEPHONE:
(415) 892-7641
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Leslie Wilson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:18 PM
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02/21/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 3 residents in care. Facility approved/cleared for 4 non-ambulatory and hospice waiver for 2.

At approximately 9:30am, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored and secured.

All rooms were equipped with lighting, nightstand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available in hallway closet. Water temperature in sinks accessible to residents in care were measured at 115.3 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2025. Smoke/Carbon Monoxide detectors located throughout the facility are operational. Toxins, sharps and other items that could pose threat if available to residents were located in the garage and in the kitchen and found to be secured. LPA observed living room and dining area to be cluttered with medical equipment such as wheel chairs (see complaint number 21-AS-20250214163627 for deficiency). Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 3 resident records. 1 out of 3 residents were missing their needs and service plan (Technical Violation). LPA conducted review of 2 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training. 2 our of 2 staff have expired 1st Aid & CPR certification (Technical Violation).


No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/21/2025:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Updated Liability Insurance
LIC610E- Emergency Disaster Drill (review, update if needed)

Exit interview conducted with Administrator and a copy of this report was provided.

Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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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