Sundance Villa

Type of visit: Case Management - Legal/Non-compliance

07/14/2026; Licensing Program Analyst (LPA) Loera conducted a Case Management - Legal/Non-compliance Inspection and met with Staff Member, Loida Montejo. LPA conducted a walk-through of the facility, that was found at a comfortable temperature with exits free from obstruction. This facility was placed on non-compliance on July 23rd, 2025 for a two-year term. LPA went over compliance plan and reminded facility of the below agreement of 07/23/2025 between Community Care Licensing (CCL) and Facility, Sundance Villa Inc: - Facility failed to provide adequate care resulting in hospitalization of a resident due to pressure wounds - Insufficient care and supervision - Facilities future compliance - Administrator Qualifications and Duties - Resident records Copy of report was provided with Staff Member.the state’s words, verbatim · CDSS document, Jul 14, 2026

Type of visit: Case Management - Legal/Non-compliance

04/07/2026, Licensing Program Analyst (LPA) Loera arrived unannounced to conducted a Case Management - Legal/Non-compliance Inspection. Upon arrival, LPA was greeted by an individual (I1) who stated they do not work at the facility. The individual stated the administrator and other staff member had left and they were called to cover the facility during their absence. LPA contacted facility Administrator via phone and notified them they were at the facility and had sent the individual home as they were not background cleared and associated to the facility. (*Civil Penalty being assessed in the amount of $500) Administrator, Leslie Wilson arrived at approximately 4:30pm. This facility was placed on non-compliance on July 23rd, 2025 for a two-year term. LPA went over compliance plan and reminded facility of the below agreement of 07/23/2025 between Community Care Licensing (CCL) and Facility, Sundance Villa Inc: - Facility failed to provide adequate care resulting in hospitalization of a resident due to pressure wounds - Insufficient care and supervision - Facilities future compliance - Administrator Qualifications and Duties - Resident records 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 additional civil penalties. Copy of report, appeal rights, LIC421IM and confidential names form were provided.the state’s words, verbatim · CDSS document, Apr 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80019(e)(2) · Plan of correction due date: Apr 10, 2026

80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or.......... :This requirement is not met as evidenced by: based on observation the licensee did not comply with the section cited above as individual (I1) was not cleared in Guardian and not associated with the facility. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: Administrator to come up with a plan as to when they need to leave the facility who will be attending to the residents. Administrator to submit plan to CCL by 04/10/2026. *$500 civil penalty is being assessed*

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Loera conducted a Case Management - Legal/Non-compliance Inspection and met with Leslie Wilson, Administrator. LPA conducted a walk-through of the facility, that was found at a comfortable temperature with all exits free from obstruction. This facility was placed on non-compliance on July 23rd, 2025 for a two-year term. LPA went over compliance plan and reminded facility of the below agreement of 07/23/2025 between Community Care Licensing (CCL) and Facility, Sundance Villa Inc: - Facility failed to provide adequate care resulting in hospitalization of a resident due to pressure wounds - Insufficient care and supervision - Facilities future compliance - Administrator Qualifications and Duties - Resident records Copy of report was provided with Administrator.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Required - 1 Year

01/21/2026, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. There are currently two residents in care. Facility approved/cleared for four non-ambulatory and hospice waiver for two. 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. All rooms were furnished per regulation. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 106.3 degrees F, within the range of 105 to 120 degrees F. Fire extinguishers were last inspected February 2025. Toxins are located in the hallway closet. Sharps are stored in a cabinet located in the kitchen. Medications were found to be centrally stored. LPA conducted spot medication count and found prescription medication to be missing expiration/start dates (Technical Violation). LPA conducted a review of two resident records. LPA observed resident R1 and R2 to not have needs and service plan and pre admission appraisal (Deficiency Cited). R2 did not have a personal rights form (Technical Violation). LPA conducted review of two staff records/training. Upon a review of staff records, LPA found staff (S1) to not have a health screening/tb test on file. Per conversation with administrator, they have the documents but were unable to find them during the inspection. LPA was unable to review S2's personnel file as the facility was unable to locate the file during the inspection (Deficiency Cited). continued on LIC809C Administrator certificate for Leslie Wilson is current from 05/08/2024 - 05/07/2026. The following documents were requested and are to be submitted to Community Care Licensing (CCL) by 02/21/2026: LIC500- Personnel Report Emergency Disaster Plan (review, update if needed) The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Loera conducted a Case Management - Legal/Non-compliance Inspection and met with Leslie Wilson, Administrator. LPA conducted a walk-through of the facility, that was found at a comfortable temperature with all exits free from obstruction. This facility was placed on non-compliance on July 23rd, 2025 for a two-year term. LPA went over compliance plan and reminded facility of the below agreement of 07/23/2025 between Community Care Licensing (CCL) and Facility, Sundance Villa Inc: - Facility failed to provide adequate care resulting in hospitalization of a resident due to pressure wounds - Insufficient care and supervision - Facilities future compliance - Administrator Qualifications and Duties - Resident records Copy of report was provided with Administrator.the state’s words, verbatim · CDSS document, Sep 22, 2025

Allegation investigated: Neglect/Lack of Supervision resulting in unexplained injury Facility did not see timely medical care Reporting Requirements

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 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.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 21-AS-20250227102506

Type of visit: Office

Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Kimberley Mota and Licensing Program Analyst Anthony Loera met with Licensee/Administrator Leslie Wilson to address areas of non-compliance. In December of 2024, the Department received a complaint alleging Neglect/Lack of Supervision resulting in Severe Injury and Staff allowed a resident to be soiled for extended periods of time – Based on the complaint investigation the Department substantiated the allegations that Neglect/Lack of Supervision resulting in Severe Injury and Staff allowed a resident to be soiled for extended periods of time. The following areas of non-compliance were addressed during the meeting today: - Facility failed to provide adequate care resulting in hospitalization of a resident due to pressure wounds - Insufficient care and supervision - Facilities future compliance - Administrator Qualifications and Duties - Resident records In today's meeting, it was discussed that The Department has additional civil penalties under review for complaint 21-AS-20241209095001. Additionally, the Department is investigating complaint allegations Neglect/Lack of Supervision resulting in unexplained injury, Facility did not see timely medical care and, Reporting Requirements for complaint # 21-AS-20250227102506 received 02/27/2025. Facility is being put on a two-year non-compliance plan. Facility will be referred for Technical Support. Resources were provided.the state’s words, verbatim · CDSS document, Jul 23, 2025

Allegation investigated: Staff left resident in soiled diapers for an extended period of time

On 06/03/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegation. LPA arrived and met with Administrator, Leslie Wilson. During the investigation, LPA conducted interviews, reviewed documents and made observations. Complainant alleges, Staff left resident in soiled diapers for an extended period of time. Based upon department document review and interviews, information provided was contradicting with a lack of corroborating evidence to support the allegation. During the investigation the LPA was unable to gather information to support if resident (R1) was left soiled in diapers for an extended period of time. LPA was informed by R1s responsible party they had no concerns regarding R1s care. In addition, a review of R1’s medical records does not show evidence that R1 was left in soiled diapers for an extended period of time. Although the allegation 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 21-AS-20250214163627

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

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 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 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)the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 21-AS-20241209095001

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 4, 2025

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: 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.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 4, 2025

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. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: 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.

Allegation investigated: Maintence and Operation

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. Substantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2025 · control 21-AS-20250214163627

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 7, 2025

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........ 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.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: 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.

Allegation investigated: Staff have inappropriate visiting hours

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, Staff have inappropriate visiting hours. Report was received 02/14/2025, alleged visiting hours start late. Based upon department document review, information provided was contradicting with a lack of corroborating evidence to support the allegation. Resident(s) admission agreement(s) state visiting hours are 1pm to 5pm and were signed by resident(s) responsible parties. Hours of visiting are posted on facilities front door. Although the allegation 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 21, 2025 · control 21-AS-20250214163627

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Mar 6, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.