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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
286804069
Report Date:
07/11/2022
Date Signed:
07/11/2022 12:58:32 PM
Document Has Been Signed on
07/11/2022 12:58 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:
HUMPHREY, KIM
FACILITY TYPE:
740
ADDRESS:
3255 VILLA LANE
TELEPHONE:
(707) 252-3333
CITY:
NAPA
STATE:
CA
ZIP CODE:
94558
CAPACITY:
86
CENSUS:
64
DATE:
07/11/2022
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Administrator, Kim Humphrey
TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/11/2022 to conduct a case management inspection regarding an SOC341 received by Community Care Licensing on 06/30/2022. LPA met with administrator Kim Humphrey.
During the inspection LPA interviewed staff and reviewed resident records. Facility will send follow up notes concerning SOC341 pending Wellness Coordinator's return to the facility.
LPA and administrator discussed yearly resident assessments for memory care unit residents.
Exit interview conducted with administrator and a copy of this report left for the facility.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Erik Gonzalez Campos
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/11/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/11/2022
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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