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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 09/01/2022
Date Signed: 09/01/2022 01:07:44 PM


Document Has Been Signed on 09/01/2022 01:07 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:
09/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Kim HumphreyTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted a case management inspection on 09/01/2022 as a follow up to several SOC 341s received by Community Care Licensing on 08/22/2022, 08/23/2022, and 08/29/2022. LPA met with administrator, Kim Humphrey

SOC341s reported incidents regarding resident on resident and resident on staff altercations in memory care unit. During the inspection LPA received copies of incident narratives and clarification on the circumstances of the incidents. Facility has implemented measures to address resident behavior.

LPA conducted exit interview with administrator and a copy of this report was printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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