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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 08/27/2024
Date Signed: 08/27/2024 12:00:38 PM


Document Has Been Signed on 08/27/2024 12:00 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, THEFACILITY NUMBER:
286804069
ADMINISTRATOR:DORLA LICAUSIFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: 61DATE:
08/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dorla LicausiTIME COMPLETED:
12:15 PM
NARRATIVE
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At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management in regards to an incident report submitted to the department on 08/26/2024. LPA met with Executive Director Dorla Licausi and reviewed records. On 08/17/2024, Resident, R1, received a wrong dose of medication. After R1 had already taken the pills, staff noticed it was the incorrect amount of medication. Physician was notified and informed staff to observe resident for changes. The amount of this medication has been changed several times in the past few months and the medication was not flagged when the dose changed the last time. Staff was retrained on facility medication practices to ensure an error does not occur in the future. ***This is a repeat violation of the same code section in a 12 month period. An immediate Civil penalty is being issued in the amount of $250.***

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Dorla Licausi and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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Document Has Been Signed on 08/27/2024 12:00 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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed
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Facility conducted retraining for responsible staff. POC cleared at time of visit.
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Licensee did not ensure R1 received the correct amount of medication. This poses an immediate Health risk to residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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