216803333-4-3-2025-21-AS-KMOA-DFLLYA-20250410091001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803333
Report Date: 04/03/2025
Date Signed: 04/03/2025 03:38:47 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2024 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20241209095001

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:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Leslie Wilson, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulting in Severe Injury
Staff allowed a resident to be soiled for extended periods of time

INVESTIGATION FINDINGS:

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On 04/03/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Administrator, Leslie Wilson. During the investigation, LPA reviewed records, conducted interviews with staff and outside parties, and made observations.

Compliant alleges, Staff allowed a resident to be soiled for extended periods of time and neglect/lack of supervision resulting in severe injury.

Based on departments review of records, Resident (R1) was admitted to facility on 11/22/2024. Per R1s physician’s report (signed but not dated by physician), R1 had both bowel and bladder impairment, required continuous bed care but no history of skin condition or breakdown. R1 had mild cognitive impairment, able to follow instructions, able to communicate needs at times. R1 had no capacity for self-care and unable to administer own prescription and PRN medications.

continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20241209095001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 04/03/2025

NARRATIVE

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R1 was unable to independently transfer to and from bed and considered bedridden (for purposes of fire clearance, both physical and mental condition). Per Admission Agreement (signed by responsible party) on 11/26/2024 and administrator on 11/23/2024) facility was responsible for assistance with personal activities of daily living – dressing, eating, toileting, bathing, grooming, mobility tasks and oral hygiene.

The department received an incident/injury report on 12/06/2024, stating R1 was transported by ambulance to Sutter Health Novato Community Hospital due to pain, labored breathing, and bed sore. Report included administrator comments – the day after admission, administrator told resident’s son that R1 should be placed on hospice to receive comfort care due to moaning continuously. Hospice by the Bay Health sent R1’s responsible party (RP) a “Physician Order Form” to sign and send back to hospice, but RP denied receiving form. R1 was not admitted to hospice. Administrator had to call 911 for medical treatment of R1.

On 12/06/2024 R1 was admitted to Sutter Health Novato Community Hospital, Admission Diagnoses (but not limited to): Pneumonitis (inflammation in the lung tissue) due to inhalation of food and vomit; unspecified severe protein-calorie malnutrition; Myocardial infarction type 2; Encephalopathy (a change in how the brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness). Per npiap.com staging of Pressure Injuries, the pictures taken on 12/06/2024 of R1’s wounds are comparable to: Sacrum – because of the presence of eschar (dead tissue) in the wound itself that obscure the extent of tissue loss, this can be classified as Unstageable Pressure Injury (P1). Left and right heels also have eschar, thereby both wounds are also unstageable.

Due to lack of available records, it could not be ascertained if R1 was on hospice at time of admission to hospital. Based on R1s LIC602, neither box (yes/no) was checked to indicate if R1 was receiving hospice care or not. Also, based on the Unusual Incident Report submitted by the facility on 12/06/2024, it indicates that R1 was not admitted to hospice. However, any resident being on hospice does not relieve the facility from providing proper care and observation of the resident. There were no records available for review if facility contacted R1’s PCP when they saw the changes on R1. Despite having Failure to Thrive (FTT), R1’s pressure injuries did not develop on the day R1 was sent to the hospital. Likely developed over a period of time prior to hospitalization due to presence of eschar. If R1 was being provided care by staff, they would have noted initial redness on R1’s sacral and heel areas. The areas in question are also pressure points which suggest that R1 was inadequately turned and repositioned. There’s no evidence if facility provided a pressure relieving mattress for R1.

continued on LIC9099-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20241209095001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 04/03/2025

NARRATIVE

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Facility only called EMS when they noted R1 with shortness of breath, cough, and desatting to 91-92% on room air and foul-smelling urine. R1 was incontinent, per npiap.com - Pressure injury prevention included skin care. It is vital to cleanse the skin promptly after episodes of incontinence. There was no Needs and Service Plan available for review that should have addressed R1’s incontinence and having been noted to require continuous bed care, R1 was likely to develop pressure injuries if no appropriate action was taken. It should be noted that R1 was admitted to facility with no history of skin condition or breakdown. There was no documentation to prove facility had notified R1’s PCP (for treatment orders or possible transfer to a higher level of care) and responsible party of the presence of the pressure injuries on R1. Facility’s neglect to provide proper turning and positioning, provide proper and timely incontinence care all lead to R1’s skin breakdown.

Based on the departments observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, is being cited on the attached LIC 9099D. Appeal rights given.

An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care.

The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20241209095001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall conduct retraining for all staff on the care and supervision of residents. Proof of scheduled training shall be submitted to CCLD by 04/04/2025.
	8 9 10 11 12 13 14	Based on records reviewed, Administrator did not ensure R1 received ongoing medical care for a worsening wound, resulting in R1s hospitalizion. This poses an Immediate Health, Safety or Personal Rights risk to persons in care. An immediate Civil Penalty is being issued in the amount of $500.	8 9 10 11 12 13 14
Type A 04/04/2025 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on records reviewed, Administrator allowed R1 to be soiled for an extended period of time.	1 2 3 4 5 6 7	Administrator shall conduct retraining for all staff on the care and supervision of residents. Proof of scheduled training shall be submitted to CCLD by 04/04/2025.
	8 9 10 11 12 13 14	This poses an Immediate Health, Safety or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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