286804069-10-14-2025-21-AS-BMOS-DMMT3V-20251020142256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804069
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:35:49 PM

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
08/21/2025 and conducted by Evaluator Julie Florio

COMPLAINT CONTROL NUMBER: 21-AS-20250821122246

FACILITY NAME:	INN ON VILLA LANE, THE		FACILITY NUMBER:	286804069
ADMINISTRATOR:	DORLA LICAUSI		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LANE		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	86	CENSUS: 78	DATE:	10/14/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dorla Licausi, Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff does not ensure records are properly maintained.
Staff handles resident in a rough manner.
Staff does not ensure residents are spoken to in an appropriate manner.
Facility does not ensure staff is in good health to perform the duties of her position correctly.
Staff do not ensure residents receive adequate care and supervision resulting in un-witnessed falls.
Staff does not ensure reporting requirements are being followed.

INVESTIGATION FINDINGS:

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On 10/14/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250821122246 investigation findings regarding the above allegations and met with Dorla Licausi, Administrator. Reporting Party (RP) alleges that Staff 1 (S1) does not ensure records are properly maintained; handles resident in a rough manner; and does not ensure residents are spoken to in an appropriate manner. RP further alleges that facility staff does not ensure staff is in good health to perform the duties of her position correctly; do not ensure residents receive adequate care and supervision resulting in un-witnessed falls; and does not ensure reporting requirements are being followed.

LPA Florio conducted 10-day complaint investigation visit on 08/22/2025 and obtained documents, made observations, and conducted an interview.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250821122246

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: 10/14/2025

NARRATIVE

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Continued from LIC9099...

Today, on 10/14/2025, LPA obtained additional documents, made observations, and conducted a further interview with Staff 2 (S2) which revealed that there is no documented proof that S1 did not ensure records were properly maintained and any errors made were corrected resulting in no harmed to any residents. Additionally, based on interviews with Staff 3 (S3) on 08/22/2025 and S2 today, progress notes from 05/29/2025 through 08/26/2025 and shower skin assessments from 07/31/2025 through 08/25/2025, and observations made of R1, each revealed no evidence of bruising or reports of R1 being handled in a rough manner. Rather, LPA did obtain Unusual Incident/Injury Reports for incidents dated 06/29/2025 and 08/18/2025 where R1 experienced falls. These interviews also revealed that there was no proof that S1 used foul language or spoke inappropriately to Resident 2 (R2). Per a Physician's Report dated 03/12/2025, R2 is in late stage dementia, is disoriented, and experiences hallucinations. Further, both interviews with S2 and S3 revealed that S1 was never been observed under the influence of any substances during work, and a health screening dated 06/14/2025 and TB test dated 06/16/2025 revealed that S1 was cleared and in good health. In regards to adequate care and supervision, per a facility personnel roster dated 06/10/2025 and facility staffing schedules dated 06/12/2025 and 10/05/2025 as well as an interview with S2, it was revealed that the facility is adequately staffed with at least 5-6 staff present from 6am-3pm in memory care, which currently has 20 residents; 2 caregivers and 1 medication technician present for the evening shift; and two staff on the night shift. Lastly, regarding reporting requirements, LPA was unable to find any evidence to support that the facility is not doing so. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegations.

Based on interviews conducted, observations made, and records obtained, the allegations that staff does not ensure records are properly maintained; handles resident in a rough manner; and does not ensure residents are spoken to in an appropriate manner. RP further alleges that facility staff does not ensure staff is in good health to perform the duties of her position correctly; do not ensure residents receive adequate care and supervision resulting in un-witnessed falls; and does not ensure reporting requirements are being followed are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025

LIC9099 (FAS) - (06/04)

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