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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 02/04/2026
Date Signed: 02/04/2026 03:05:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
01/30/2026 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20260130150310
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: 77DATE:
02/04/2026
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dorla Licausi, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are mismanaging resident medication
INVESTIGATION FINDINGS:
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On 02/04/2026, at approximately 1:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to initiate a 10-day complaint investigation and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260130150310, which was received by Community Care Licensing (CCL) on 01/30/2026. Reporting Party (RP) alleges that staff are mismanaging resident medication. LPA met with Dorla Licausi, Administrator.

During visit, LPA obtained documents and conducted interviews. Per Incident Report (IR) dated 02/04/2026, Centrally Stored Medication Destruction Records (CSMDRs) and Medication Administration Records (MARs) for both Resident 1 (R1) and Resident 2 (R2), Controlled Drug Record for R1, Narcotic Count Sheet for R2, and interviews with both Staff 1 (S1) and the facility Administrator, it was revealed that S1 made a medication error on 01/28/2026 by giving R1 a dose of medication from R2's medication container.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20260130150310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 286804069
VISIT DATE: 02/04/2026
NARRATIVE
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Continued from LIC9099...

They were the same medication but different doses. No harm to either resident was reported. Per Administrator and IR, S1 will undergo retraining and coaching for the incident.

Based on documents obtained and interviews conducted, the allegation that staff are mismanaging resident medication is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20260130150310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 286804069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2026
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Licensee to submit proof of coaching and retraining with S1 to CCLD by POC due date of 03/06/2026.
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Based on records reviewed and interviews conducted, Licensee did not ensure that R1 received their medications as prescribed. This poses a potential Health, Safety and/or Personal Rights 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3