286804069-9-11-2023-21-AS-BMOS-CWVMR3-20231023094940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:15:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/29/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230629171636

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: 59	DATE:	09/11/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kim Alsup-Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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MEDICATIONS ARE NOT BEING PROVIDED AS ORDERED
SPECIAL DIET, INCLUDING LIQUIDS, ARE NOT BEING PROVIDED AS ORDERED

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/11/23 at approximately 10:00am, LPA met with Interim Administrator Kim Alsup, and Dylan Nunn, Resident Service Directorr, LVN.

LPA reviewed resident (R1) records, including medical assessment, care plan, appraisal(s), medical documents, Dr.ordered special diet(s), and resident's prescription orders. LPA reviewed information provided to the Department regarding the allegations. LPA conducted interviews with staff (S1, S2, S3), and other interested party(s).

The investigation revealed that R1 has a Dr's Order for all liquids to be given thickened/nectar thick due to difficulty swalowing, and for food to be provided in a chopped texture to the resident (at the time of the incidents). R1 has a Dr's Order for medications to be given to the resident in applesauce and provided with thickened liquids.

Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

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-20230629171636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/11/2023

NARRATIVE

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LPA reviewed facility document on R1 named "ADL Care Details" dated 6/27/23, with the following information: Eating/Diet: Resident able to consume meals independently, aspiration precautions, Nectar thick liquids, Mechanical chopped texture. Offer fluids, ensure resident is to be sitting upright to prevent aspiration. Medications: Medication assistance with Med-Aide on duty, resident to sit-fully upright, takes meds whole in applesauce and nectar thick liquids. The LPA reviewed obtained photos showing R1 being fed food by staff, on two separate occasions, while in a halfway lying position in their bed. LPA observed in the photos, staff did not have the resident sitting upright when providing food, to help prevent resident from aspirating. Per review of resident records, All food and liquids are to be provided to the resident (R1) while in an upright sitting position. Resident incidents did occur where the resident went out 911 due to choking on food, and/or aspirating. Per investigation, facility staff were aware of R1's specific Dr's Orders regarding medications and food/drinks.

Administrator Alsup, Chancellor Consultant Regional staff, stated that they came into the facility, July 2023, in regards to the concerns with R1's medication assistance by staff, and food & liquids being provided by staff, concerns that Dr's Orders were not being followed by staff. Administrator Alsup, and facility LVN Nunn, reviewed incidents, and held in-service training(s) with all staff, including caregivers, med-technicians, and kitchen staff, regarding R1's care plan and Dr's Orders.

Based on LPA interviews, review of records, photos and information obtained, the investigation has revealed that the allegations of "Medications are not being provided as ordered" and "Special diet, including liquids, are not being provided as ordered" are substantiated.

Due to the substantiation of the allegation(s), a citation, 87465(a)(4) Incidental Medical & Dental Care-The licensee shall assist residents with self-administered medications as needed, will be cited today, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Appeal Rights Given.
Exit interview conducted with the Administrator Kim Alsup

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230629171636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/12/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidental Medical & Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: The LPA reviewed obtained photos showing R1 being fed food by staff, on two separate occasions, while in a halfway lying position in their bed.	1 2 3 4 5 6 7	CORRECTED BY LICENSEE/ADMINISTRATOR HAD AN IN-SERVICE TRAINING OF R1'S CARE PLAN, INCLUDING ALL DR'S ORDERS, WITH ALL CAREGIVERS, MED-TECHS, AND KITCHEN STAFF;
	8 9 10 11 12 13 14	LPA observed in the photos, staff did not have the resident sitting upright when providing food, to help prevent resident from aspirating. Per review of resident records, All food and liquids are to be provided to the resident (R1) while in an upright sitting position. Resident incidents did occur where the resident went out 911 due to choking on food, and/or aspirating. This is a health & safety risk, and a risk to residents personal rights.	8 9 10 11 12 13 14	TRAINING WAS CONDUCTED, BY ADMINISTRATOR ALSUP AND LVN NUNN. ADMINISTRATOR PROVIDED INFORMATION & COPIES OF TRAINING TO THE LPA. POC CLEARED TODAY, 9/11/23.
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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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023

LIC9099 (FAS) - (06/04)

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