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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803333
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:17:16 PM


Document Has Been Signed on 03/06/2024 04:17 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:WILSON, LESLIEFACILITY TYPE:
740
ADDRESS:1414 CAMBRIDGE STREETTELEPHONE:
(415) 892-7641
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:4CENSUS: 2DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator, Leslie WilsonTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 12:35PM to conduct an Annual Required inspection, and was greeted by staff. LPA met with Administrator, Leslie Wilson. LPA and Administrator discussed the purpose of the visit.

LPA initiated a tour of the facility around 12:40PM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 and 116 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. LPA observed drawer containing knives was unlocked. LPA and Administrator discussed getting a lock for the drawer.

Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the garage. Fire extinguishers were last serviced February 9, 2024. Smoke and carbon monoxide detectors located throughout the facility were tested and operational during inspection. Per conversation with Administrator, facility does not conduct fire/disaster drills.

2 staff files and 2 resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. 2 of 2 residents did not have a required needs and services plan. 2 of 2 staff did not have a medical assessment or tuberculosis screening on file. Administrator Certificate for Administrator, Leslie Wilson (6020174740) is up to date and expires 05/07/2024. Medications and medication records were reviewed.

Continued on LIC809C
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNDANCE VILLA INC.
FACILITY NUMBER: 216803333
VISIT DATE: 03/06/2024
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Continued from LIC809

Licensee/Administrator to submit updates of the following documents by 04/06/2024:
LIC 500 Personnel Summary
LIC 9020 Register of Residents
Copy of Liability Insurance
Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on forms confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 03/06/2024 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Administrator agrees to send a written plan addressing how facility will ensure their current (and future) staff will get required health screening documents and TB tests done before beginning working in the facility by POC due date of 03/07/2024. Administrator agrees to send proof of health screening including TB test results for 2 of 2 staff members by 03/25/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2024 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator agrees to complete appraisals for 2 of 2 residents with signatures from responsible parties on form LIC625 and submit to LPA by POC due date of 03/25/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not conducting quarterly disaster drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator agrees to submit a disaster drill log with a sign in sheet for which staff and residents attended by POC due date of 03/25/2024.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/06/2024 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator agrees to submit a plan about how the facility will ensure the resident is having all incontinence needs met, including how facility plans on keeping residents room free from strong feces odor as required by regulation. Plan to be submit to LPA by POC due date of 03/25/2024.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the knife drawer equipped with a lock which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee agrees to send photos of new lock on knife drawer, as well as a plan addressing how they will ensure residents do not have access to the knives. Plan to be submit to LPA by POC due date of 03/25/2024.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6