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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804069
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:41:09 PM


Document Has Been Signed on 04/27/2023 12:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
286804069
ADMINISTRATOR:HUMPHREY, KIMFACILITY TYPE:
740
ADDRESS:3255 VILLA LANETELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:86CENSUS: DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kim HumphreyTIME COMPLETED:
12:55 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC 341 form submitted to CCL on 03/22/2023. LPA met with Executive Director Kim Humphrey and reviewed records. The incident involved a resident having an emotional outburst and assaulting a staff member. LPA reviewed resident care plan and found plan to be updated and notes on communications with responsible person to address behaviors.
During this visit, LPA was informed of a recent incident regarding a staff member observing bruises on the arms of R1. An investigation was conducted and notifications were made to Law Enforcement and the Ombudsman's office regarding the alleged abuse. The investigation did not find evidence of physical abuse but did uncover several medication errors made by staff. This is a summary of the investigation:
During the morning medication time on 04/22/2023, 5 of 19 residents refused their medications. The medication technician, S1, made the proper notifications to the physician and responsible party and noted the medications were refused on the medication administration record, MAR. When the afternoon medication technician, S2, came on shift at 2:30PM, they told S1 they were going to give the missed medications to the residents. S2 took the missed medications from S1 and came back a short time later saying that the residents had taken their medications. S2 did not update the MAR or make any notifications. This action was in violation to physician orders and possibly could have done harm to residents. The 5 residents were observed closely for any side effects.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Kim Humphrey and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2023 12:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on
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Licensee became aware of several medication errors on 04/24/2023. An investigation was conducted and responsible staff was terminated on 04/26/2023. All staff have received refresher training on abuse reporting.
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interviews, Licensee did not ensure 5 of 19 residents received medications per physician orders. This poses an immediate Health risk to residents in care.
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Medication technicians recieved refresher training on medication assistance, and reporting policies. POC cleared at time of visit.

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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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