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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803333
Report Date: 07/31/2025
Date Signed: 07/31/2025 12:08:38 PM

Unsubstantiated


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
02/27/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250227102506
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: 1DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Leslie Wilson, AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulting in unexplained injury
Facility did not see timely medical care
Reporting Requirements
INVESTIGATION FINDINGS:
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On 07/31/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Administrator, Leslie Wilson. During the investigation, LPA conducted interviews, reviewed documents and made observations.

Complainant alleges, Neglect/Lack of Supervision resulting in unexplained injury, Facility did not see timely medical care, and Reporting Requirements.

Alleges neglect/lack of supervision resulting in unexplained injury. During the investigation LPA was provided with medical records indicating resident (R1) was hospitalized at Kaiser Permanente for a nontraumatic subdural hematoma with medical notes stating R1 had a recent left intracerebral hemorrhage in November 2024, went to a skilled nursing facility (SNF) where R1 was able to complete rehab before getting admitted into the facility. R1 has a history of a minor stroke in December 2023.

continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250227102506
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: 07/31/2025
NARRATIVE
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Complaint alleges facility did not see timely medical care, based on interviews conducted and document review, indicate R1 was admitted to the facility on 02/12/2025. On 02/24/2025 the facility sent R1 to the hospital after noticing R1 declining. R1 was observed to be at baseline from 02/12/2025 to 02/23/2025.

Complaint alleges reporting requirements, that the facility did not notify family. LPA was provided with conflicting information regarding the allegation. Interviews conducted with facility staff indicate after they called 911 for R1 to be sent out for medical attention, they contacted R1’s responsible party (RP) to notify that R1 was being transported to the hospital. R1s responsible party stated they contacted the facility when R1s physical therapist was present at the facility, noticed a change in condition and told the facility to call 911.

Based on record review, interviews conducted, and observations made, the allegations listed above are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
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