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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803333
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:08:41 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
02/14/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250214163627
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: 3DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Leslie Wilson, AdministratorTIME COMPLETED:
03:18 PM
ALLEGATION(S):
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Maintence and Operation
INVESTIGATION FINDINGS:
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On 02/21/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of initiating a complaint investigation regarding the above complaint and delivering complaint findings. LPA arrived and met with Administrator, Leslie Wilson. During the investigation, LPA conducted interviews with staff and made observations.

Compliant alleges, maintenance and operation. Report was received 02/14/2025, alleged facility is not free of clutter in the living room and kitchen area and facility being too cold.

Based on LPAs observations and interviews which were conducted, 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

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.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20250214163627
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: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on LPA's observation, the licensee did not comply with the section cited above in that the living room and........
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Facility to submit proof of pictures of living room and kitchen area to be cleared and cleaned. POC due date to CCL by 03/11/2025.
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kitchen area was free of clutter of medical equipement and wheelchairs which poses/posed a potential health, saftey or personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2