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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 04/30/2024
Date Signed: 04/30/2024 10:01:33 AM

Unsubstantiated


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
04/17/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240417163154
FACILITY NAME:INN ON VILLA LANE, THEFACILITY NUMBER:
286804069
ADMINISTRATOR:ALSUP, KIMBERLEEFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: 59DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dorla LicausiTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff arranged for a resident to have another resident assist them while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that facility staff made arrangements for Resident (R1) to assist another Resident(R2) by remaining in R2's room at night to remind R2 to call for assistance when needed. Through statements and document reviews, the following determinations are made: R1, R2, the Administrator and Nurse Consultant state that R1 volunteered to assist R2, who is a close friend, and that the facility staff have not requested or required R1 to provide any care or assistance to R2; There is no record indicating that the Physician for R2 has ordered night time supervision of R2 in excess of what is normally provided by staff for all residents in care. R1 and R2 state that the presence of R1 in R2's room at night is an informal arrangement which developed out of a friendship, was purely voluntary, and promulgated between themselves. Although the allegation may be true, based on statements and document reviews, there is not a preponderance of evidence to prove or disprove the allegation. Therefore, the allegation is UNSUBSTANTIATED. Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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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