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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:45:15 PM


Document Has Been Signed on 08/02/2022 02:45 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:HUMPHREY, KIMFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: 65DATE:
08/02/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Kim HumphreyTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post-Licensing Inspection on 08/02/2022. Administrator, Kim Humphrey was not available but was notified over the phone. Administrator agreed to have LPA performe inspection with Maintenance Director, Juan Mendoza. Upon arrival LPA was screened and checked in by front desk. Administrator arrived at the end of the inspection

Facility is two stories with both assisted living and memory care. LPA toured the facility with maintenance director. Facility was a comfortable temperature and exits were free from obstructions. Building and grounds were clean and in good repair. Fire extinguishers were last charged on 08/06/2021. Maintenance director indicated that facility is coordinating with fire department to have fire extinguishers recharged. Fire drill was conducted on 07/29/2022. Facility has a sprinkler system and a fire panel. Fire panel was last inspected in October of 2021. Toxins were secured on locked medication carts. Laundry is done for residents once a week, Linens/sheets are replaced once a week. Medications are centrally stored and inaccessible to residents in care. Locked medication carts were observed. Resident bathrooms had the necessary grab bars and nonslip mats. Pull cords are present in resident bathrooms. There were 3 stairwells present with 3 evacuation chairs at the top of the stairs. LPA observed daily activity schedule for the day. Required LTCO and CCL posters were present near the entrance to memory care. Sufficient perishable and non perishable food was observed in the kitchen.

LPA requested a copy of the following with two weeks of today's inspection: LIC 500 with contact information.

Exit interview conducted with administrator and a copy of this report printed for the facility.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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