286804069-1-30-2024-21-AS-MCUA-CZYV4B-20240130150603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:06:12 PM

Document Has Been Signed on 01/30/2024 03:06 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:	ALSUP, KIMBERLEE		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LANE		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	86	CENSUS:	DATE:	01/30/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:44 PM
MET WITH:	Dylan Nunn (Service Coordinator)		TIME COMPLETED:	03:21 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) Cuadra arrived at this facility unannounced to conduct a case management visit in regards to incident reports. LPA met with Resident Services Coordinator Dylan Nunn. On 12/11/23 the department received an incident report along with SOC341 notifying CCL about resident (R1) and resident (R2). Per incident report, On 12/10/23 at approximate 5pm residents were having dinner when R1 approached some residents to attempt to grab R2's arms and kiss them, even when R2 replied "No", then staff intervene to redirect R1. Responsible parties were notified. On 12/11/23, R2 reported to staff that they were feeling some mild pain in their left upper arm, and refused to seek medical care when asked by staff. After the incident, R1 was closely monitored to ensure that this type of incidents do not happen again, so far no further incidents have happened. On 1/24/24 CCL received a self-incident report regarding resident (R3) who on 1/20/24 at approximate 10:20am staff alerted medication aide that R3 was experiencing a sharp pain in their lower back and was unable to move. Per incident report, R3 stated that they were brought to urgent care by their responsible party on 1/19/24, where they were diagnosed with a compression fracture to their lower back (T12). Staff called immediately 911 and R3 was transported to the hospital for further evaluation. During today's visit, LPA interviewed facility staff to obtain information about this incident, it was confirmed that R3 sustained a fracture without their knowledge. Based on records review, R3 had a diagnosis of wedge compression fracture of T11-T12 vertebra. Currently, R3 was admitted to skilled nursing for treatment. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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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: 01/30/2024

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Continued from LIC809...

Last incident reported that on 12/25/23 an allegedly medication error was observed in the medication book by facility staff. On 12/22/23 resident (R4) at approximately 5:34am supposedly received half of the prescribed dose of Oxycodone 5mg instead of one tablet by mouth every 6 hours as needed for pain as indicated by doctor's order. Based on records review, R3 was originally prescribed Oxycodone 5mg half tablet by mouth every 6 hours for pain, but the medication was adjusted as of 12/20/23 to one tablet by mouth every 6 hours as needed for severe pain. Per narcotic count sheet, R3 was assisted with one tablet starting on 12/22/23 after medication was filled by the pharmacy. The facility provided facsimile transmittal sheet dated 12/23/23 where R3's physician was reached out for medication adjustment and physician adjusted the medication. Based on interviews conducted, it was confirmed that R3 was assisted with their adequate medication dosage.

No deficiencies cited during today's visit.

Exit interview was conducted with Resident Services Coordinator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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