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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 07/09/2025
Date Signed: 07/09/2025 10:15:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
03/21/2025 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20250321090748
FACILITY NAME:INN ON VILLA LANE, THEFACILITY NUMBER:
286804069
ADMINISTRATOR:DORLA LICAUSIFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: 75DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dorla LicausiTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Medication - not dispensing medication as prescribed by physician.
Medication - missing medication.
Neglect/Lack of Supervision - resident not repositioned.
Buildings and Grounds - staff not ensuring facility is safe sanitary and in good repair.
INVESTIGATION FINDINGS:
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At approximatley 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facliity unannounced to complete an investigation into the above allegations. LPA met with Executive Director Dorla Licausi. Based on records reviewed and interviews conducted, LPA was not able to find evidence that facility was not dispensing medication as prescribed by physician. Resident, R1, was prescribed a Fentynal patch 12mcg every 3 days, then an increase to 25mcg was ordered. Facility did not have a written order, nor were the correct patches available at the time of a verbal order. Facility began applying the correct patch when the proper documentation and patches were received. Records reviewed indicate the placement and removal of each patch. LPA did not find detailed disposal records for each patch, other than the destruction record indicating the patches were disposed of. LPA discussed with Executive Director various methods of better destruction documentation going forward. LPA reviewed medication records and did not find evidence of missing medication. Documentation of applied and removed patches matched the perscription count. Based on records reviewed, R1 did not need assistance repositioning in bed and was able to reposition themselves. Based on interviews conducted, R1 did not like certain positions and would make their needs known to staff. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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-20250321090748
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: INN ON VILLA LANE, THE
FACILITY NUMBER: 286804069
VISIT DATE: 07/09/2025
NARRATIVE
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During the course of this investigation, LPA toured the building and grounds and did not find occurrences of unsanitary areas or items that were in need of repair. LPA was informed that staff had left soiled garments on a counter top in a residents room. LPA reviewed photos and observed what appeared to be some folded, clean articles of clothing, 2 dirty dishware items in a sink and a clear plastic bag with a small, closed plastic bottle on the counter. There was no evidence of soiled garments or unsanitary conditions.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2