<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:53:36 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
12/30/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20221230092000
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: 53DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Kim HumphreyTIME COMPLETED:
03:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff spoke to resident in an inappropriate manner.
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 02/09/2023 to conduct a complaint inspection regarding the allegation that staff spoke to resident in an inappropriate manner. LPA met with administrator Kim Humphrey.

During the inspection LPA made observations and conducted resident interviews. LPA conducted 6 resident interviews, including an interview with the resident who was the subject of the allegation. 6 out of 6 residents denied ever being spoken to in an inappropriate manner. LPA reviewed regulation 84768.1 (Personal Rights of Residents in All Facilities) with administrator and emphasized that residents are to be accorded dignity in their personal relationships, with staff, residents and other persons. LPA also provided administrator with requirements for staff training, which should include training regarding resident rights. Furthermore, facility will be subject to a review of staff records during the annual inspection which will verify that training has been completed.
Continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (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 2
Control Number 21-AS-20221230092000
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
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
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.

No deficiencies cited during today’s inspection.

Exit interview conducted with administrator and a copy of this report emailed to the administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (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 2