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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:46:06 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
08/21/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250821122246
FACILITY NAME:INN ON VILLA LANE, THEFACILITY NUMBER:
286804069
ADMINISTRATOR:DORLA LICAUSIFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: 78DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dorla Licausi, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff does not ensure medications are dispensed as prescribed to residents.
INVESTIGATION FINDINGS:
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On 10/14/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250821122246 investigation findings regarding the above allegations and met with Dorla Licausi, Administrator. Reporting Party (RP) alleges that Staff 1 (S1) does not ensure medications are dispensed as prescribed to residents.

Prior to receiving this complaint, LPA Florio received an incident report on 07/30/2025, stating S1 made a medication error on 07/20/2025 with Resident 1 (R1), which did not result in harm to the resident. The report states S1 was coached and medication administration and record keeping were reviewed.

LPA Florio conducted 10-day complaint investigation visit on 08/22/2025 and obtained documents, made observations, and conducted interviews.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 3
Control Number 21-AS-20250821122246
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: INN ON VILLA LANE, THE
FACILITY NUMBER: 286804069
VISIT DATE: 10/14/2025
NARRATIVE
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Continued from LIC9099...

During this visit, an interview with Staff 3 (S3) further revealed that S1 made the medication error. On 08/27/2025, LPA received another incident report for another medication error made by S1 with Resident 2 (R2). No harm to resident was reported. An interview conducted today with Staff 2 (S2) revealed that as a result of these two medication errors, S1 has been terminated as reflected on Performance Improvement Action Plan/Termination Letter dated 08/26/2025.

Based on observations made, interviews conducted and records obtained, the allegation that staff does not ensure medications are dispensed as prescribed to residents is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250821122246
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: INN ON VILLA LANE, THE
FACILITY NUMBER: 286804069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Licensee already performed coaching and retraining with S1 on 08/01/2025 and subsequently terminated S1 on 08/26/2025.
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Based on observations made, records reviewed, and interviews conducted, Licensee did not ensure that R1 and R2 both received their medications as prescribed. This poses a potential Health, Safety and/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: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3