286804069-11-10-2022-21-AS-KMOA-CL8UYH-20221116145957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 11/10/2022
Date Signed: 11/10/2022 10:56:34 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/22/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220822154523

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: 62	DATE:	11/10/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Kim Humphrey		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow resident's special diet.
Resident was left in his room during lunch time.
Facility did not ensure that resident received nail care.
Facility did not administer medication per physicians orders.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/10/2022 to deliver findings regarding the above allegations. LPA met with administrator, Kim Humphrey.

There was an allegation that facility did not follow resident’s special diet. Reporting Party (RP) stated to LPA that resident 1 (R1) required a special diet due to medical procedure and to prevent digestive issues. During the initial inspection on 09/01/2022 LPA reviewed resident file. Physician’s report indicated a controlled diet with no further elaboration. A signed physician’s diet order indicated R1 was to be given a regular diet. Personal service assessment conducted by the facility also did not direct for a special diet. LPA conducted an interview with Staff 1 (S1). S1 stated they observed R1 frequently at mealtimes and that R1 had no dietary restrictions. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

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 2

Control Number 21-AS-20220822154523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/10/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

There was an allegation that resident was left in his room during lunch time. Staff indicated to LPA that R1 always had meals in the dining room with other residents. Per S1 and administrator the facility charges an extra fee to deliver meals to room unless resident is sick. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that facility did not ensure resident received nail care. R1 was a resident a of the facility for a period of about one month. Personal service assessment indicates that R1 did not need assistance with physical grooming tasks although the LIC 602 indicated that R1 was not capable of grooming self. LPA had discussion with administrator concerning the agreement between physician’s reports and facility assessments. LPA provided guidance to coordinate with physicians and to conduct reassessments as needed. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that facility did not administer medication per physician’s orders. Regulation 87465 (e) 2 regarding incidental medical and dental care requires a signed order with the exact dosage. RP stated to LPA that facility did not administer a medication because the dosage was missing. Record review revealed that on 03/17/2022 facility faxed R1’s physician to request clarification regarding the dosage before administering the medication. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with administrator, Kim Humphrey and a copy of this report emailed to the facility.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2