286804069-2-9-2023-21-AS-KMOA-CP52N7-20230216163217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:50:30 PM

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
01/18/2023 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20230118110739

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: 53	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Kim Humphrey		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Reporting Requirements
Items that pose a danger are accessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/09/2023 to conduct a complaint inspection regarding the above allegations. LPA met with administrator Kim Humphrey.

There is an allegation regarding reporting requirements. It is alleged that facility failed to report incidents regarding resident 1 (R1). The Santa Rosa regional office (RO) received two SOC 341s regarding R1, one on 12/06/2022 and one on 12/07/2022. Furthermore, RO received incident reports regarding R1 on 12/07/2022, 01/09/2023, and 01/27/2023. 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: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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 4

Control Number 21-AS-20230118110739

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: 02/09/2023

NARRATIVE

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There is an allegation that items that pose a danger are accessible to residents in care. R1 is alleged to have threatened staff with a knife from the dining room. R1 resides in assisted living where residents are allowed knives for meals. Knives were not accessible to residents with dementia. Administrator informed LPA of another instance in which R1 was able to obtain scissors from behind the receptionist’s desk, however these were not readily accessible. 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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
01/18/2023 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20230118110739

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: 53	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Adminsitrator, Kim Humphrey		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/09/2023 to conduct a complaint inspection regarding the above allegation. LPA met with administrator Kim Humphrey.

There is an allegation that residents’ personal rights were violated. Three out of six resident interviews revealed that residents believe R1 to be dangerous and that they are fearful of her. Two interviews revealed instances of R1 physically pushing residents. The Health and Safety Code indicates that residents are entitled to be free from intimidation, and verbal, mental, or physical abuse. The preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights were provided.

Exit interview conducted with adminsitrator. A copy of this report emailed to the facility.

Substantiated

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: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20230118110739

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/17/2023 Section Cited HSC 1569.269(a)(10)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility submit a plan for how to address R1's behavior by plan of correction date 02/17/2023
	8 9 10 11 12 13 14	Three out of six resident interviews revealed that residents are fearful and intimidated by another resident. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4