286804069-6-22-2023-21-AS-DALO-CT2TUN-20230622150236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:02:42 PM

Document Has Been Signed on 06/22/2023 03:02 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	INN ON VILLA LANE, THE		FACILITY NUMBER:	286804069
ADMINISTRATOR:	HUMPHREY, KIM		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LANE		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	86	CENSUS: 57	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Kim Humphrey-Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(LPA) Alviso conducted a Required-1 Year visit, on 6/22/23 at approximately 10:25am, and met with Administrator Kim Humphrey. Hospice care waiver approved for sixteen(16) residents. Facility has an approved dementia plan of operation. Facility has submitted the required Infection Control Plan, which is part of the facility's plan of operation. Facility has a required emergency disaster plan, including evacuation. Last fire drill was 6/15/2023, per review of records. Fire clearance approval is for 86 non-ambulatory residents, which includes 10 bedridden. Rooms approved for bedridden use are 117, 118, 119, 120, 121, 134, 136, 137, 138,139. Facility is two stories with both assisted living and memory care. LPA toured the facility with the Administrator. All exits were unobstructed. All fire extinguishers randomly checked, were serviced and tagged as required, expires 8/11/23. All stairwells, three(3), had evacuation chairs as required. Medications were locked and inaccessible to residents in care. All toxins were locked up and inaccessible to residents as required. The facility was at a comfortable temperature. The facility had sufficient lighting in common areas, hallways, and bathrooms for use by all. Resident rooms checked, had sufficient lighting, grab bars, and non-skid flooring/bath mats for use by residents as needed. Facility had supplies to meet the 72 hour shelter in place requirement. Hot water was checked at 108.3F which is within regulation requirements. Facility had a sufficient supply of perishable and non-perishable food. Continued on LIC809C.....

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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Document Has Been Signed on 06/22/2023 03:02 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
CCLD Regional Office, 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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411( c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA’s file review, three(3) out of five(5) staff, S1, S3, & S5, didn’t have current first aid certification as required, the licensee did not comply with the section cited above in [3] out of [5] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all staff have required first aid certification per regulations. Licensee to have named staff obtain first aid recertification; Submit copies of staff's current first aid certification no later than 7/3/23. POC due 7/3/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: INN ON VILLA LANE, THE	FACILITY NUMBER: 286804069
	VISIT DATE: 06/22/2023

NARRATIVE

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LPA reviewed five(5) resident files. All resident files were found to be complete.

LPA reviewed five(5) staff files, including training. All staff have criminal record clearance as required. Three(3) out of five(5) staff lacked current first aid certification, S1, S3, and S5, all three staff provide direct care to residents. This deficiency will be cited, 87411( c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.

Administrator to submit updates of the following documents by 7/22/2023:
LIC 500 Personnel Summary
LIC308 Designation of Facility Responsibility
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Deficiencies 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 the Administrator.
Appeal rights provided to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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