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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 07/19/2024
Date Signed: 07/19/2024 01:52:38 PM


Document Has Been Signed on 07/19/2024 01:52 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 58DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dorla Licuasi, AdministratorTIME COMPLETED:
02:07 PM
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On 07/19/2024 at approximately 09:15am, Licensing Program Analyst (LPA) J. Macias arrived to conduct an unannounced required Annual Inspection and met with Administrator, Dorla Licausi. Facility contact information was reviewed. Fees are current at the time of visit. Facility is two stories with both assisted living and memory care.

At approximately 10:00am, LPA and Administrator toured the facility & grounds, which included resident apartments, kitchens, food storage, dining rooms, and various common areas used by residents. Facility provides different types of activities which include painting, dominos, and various games. Facility was at a comfortable temperature and was found to be clean and in good repair. Resident rooms were furnished per regulation and had sufficient lighting, grab bars and non-skid bath mats for use by residents as needed. Water temperature in various restroom sinks accessible to residents in care were all within the range of 105 to 120 degrees F allowed per regulation. LPA observed all walkways and exits to be unobstructed. All stairwells had evacuation chairs as required. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation. All toxins were locked up and inaccessible to residents as required. Medications are centrally stored in a secured room and inaccessible to residents. Medications were reviewed and found no deficiencies.

At approximately 11:00 am, LPA reviewed five (5) resident files. All resident files were found to be complete with all required documentation.
At approximately 12:00 pm, LPA reviewed six (6) staff records, which were all found to be well organized, thorough, and contained the required documentation. First Aid and CPR certification were current in staff files reviewed.

All fire extinguishers were current and charged as of August 23, 2023. Facility has Fire alarm system that is serviced by an outside vendor that was last inspected on 04/18/2024. Last fire drill was conducted on 6/11/2024, per review of records.

Administrator to submit updates of the following documents by 8/19/2024:
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)

Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
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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