Inspection Reports for The Inn on Villa Lane

The inspection was conducted as a case management - incident visit to obtain more information regarding an incident report received about a resident who eloped from the facility after attending a community event.

The facility was cited for not providing necessary services to meet resident needs, specifically due to lack of supervision outside the memory care unit which led to the resident's elopement, posing an immediate health, safety, and personal rights risk.

The visit was complaint-related, triggered by an incident report received on 08/28/2025 regarding an incident on 08/27/2025 involving a memory care resident who eloped from the facility.

The visit was an unannounced case management - incident inspection to obtain more information regarding two incident reports involving staff and residents, which were part of a complaint investigation received by the Department.

The inspection followed up on two incidents involving staff and residents, resulting in a citation issued under the complaint investigation. An exit interview was conducted with the Administrator.

The visit was triggered by complaint investigation #21-AS-20250821122246 related to two incidents involving Staff 1 and Residents 1 and 2, with a citation issued.

The inspection was a required unannounced 1-year annual inspection of the Residential Care Facility for the Elderly (RCFE).

The facility was found to be in compliance with regulations including safety measures, emergency preparedness, staff and resident file documentation, medication management, and environmental conditions. No deficiencies were explicitly listed in the report.

The inspection was a case management-incident visit conducted to obtain more information regarding an incident that occurred on 2025-05-31 involving multiple residents and a staff member, as reported by the Executive Director via email and incident reports.

No deficiencies were cited during the visit. The Licensing Program Analyst obtained records, made observations, and conducted an interview with the Executive Director.

An unannounced complaint investigation was conducted in response to allegations received on 2024-12-11 regarding staff failing to call emergency services, prevent residents from smoking indoors, sleeping on the floor, entering other resident rooms, and interfering with care needs.

The investigation found no evidence to substantiate the allegations. Records and interviews showed emergency services were called when needed, a strict no-smoking policy was enforced though residents sometimes chose to smoke indoors, residents were occasionally found sleeping in public areas or other resident rooms but were assisted back to their rooms, and no evidence was found of residents interfering with others' care needs.

The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations occurred.

The visit was an unannounced case management inspection conducted in response to an incident report submitted on 2024-08-26 regarding a medication error involving a resident.

The facility failed to ensure a resident received the correct amount of medication, posing an immediate health risk. This was a repeat violation within 12 months, resulting in a $250 civil penalty and staff retraining on medication practices.

The visit was triggered by a complaint/incident report regarding a medication error where resident R1 received a wrong dose of medication. The violation was substantiated as a repeat offense within 12 months.

The inspection was an unannounced required Annual Inspection conducted to evaluate compliance with licensing regulations for the facility.

The facility was found to be clean, in good repair, and compliant with regulations regarding resident rooms, water temperature, food storage, medication storage, and staff documentation. No deficiencies were found in medication management or resident and staff files. Fire safety equipment and drills were current.

Unannounced visit/investigation of a complaint alleging that facility staff arranged for a resident to have another resident assist them while in care.

The investigation found that the arrangement for one resident to assist another was voluntary and informal, with no staff request or requirement for such assistance, and no physician order for additional supervision. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff arranged for Resident 1 to assist Resident 2 by remaining in Resident 2's room at night to remind them to call for assistance. The allegation was found unsubstantiated.

The visit was an unannounced case management visit conducted to review incident reports involving residents and medication administration.

The report detailed incidents involving resident interactions and a medication error that was corrected. No deficiencies were cited during the visit.

An unannounced complaint investigation was conducted due to an allegation that staff were mismanaging residents' medication.

The investigation found that the facility did not mismanage residents' medication. The delay in medication refills was due to the physician not responding timely, and no residents missed any prescribed doses. The complaint was determined to be unfounded.

The complaint alleging medication mismanagement was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.

Unannounced complaint investigation conducted due to allegations that medications and special diets, including liquids, were not being provided as ordered to a resident.

The investigation substantiated that medications and special diets were not provided as ordered, including failure to provide liquids thickened as prescribed and feeding the resident in a non-upright position, which led to choking and aspiration incidents.

The complaint investigation was substantiated. Allegations included medications not being provided as ordered and special diets, including liquids, not being provided as ordered. The resident experienced choking and aspiration incidents. Staff were aware of doctor's orders but failed to comply. Training was conducted post-investigation.

The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing regulations and facility operation standards.

The facility was generally compliant with safety, emergency, and operational requirements, including fire safety and infection control plans. However, a deficiency was cited for three out of five staff lacking current first aid certification, posing a potential health and safety risk.

The visit was an unannounced case management inspection conducted in response to a medication error incident at the facility.

The facility was found to have given a resident the wrong dose of medication, administering another resident's medication without verifying the name. This was a repeat violation within 12 months. The facility conducted an investigation and staff retraining. A civil penalty of $250 was issued.

The visit was triggered by a medication error complaint. It was a repeat violation within 12 months and a civil penalty was issued.

The visit was an unannounced case management inspection triggered by an SOC 341 form submitted on 03/22/2023, related to a resident's emotional outburst and assault on a staff member, as well as an investigation into alleged physical abuse due to bruises observed on a resident.

The investigation found no evidence of physical abuse but identified several medication errors involving five residents who did not receive medications per physician orders. The medication technician failed to update records or notify responsible parties, posing an immediate health risk. A deficiency was cited and a plan of correction was implemented.

The complaint involved alleged physical abuse of a resident due to bruises observed on the resident's arms. The investigation did not substantiate physical abuse but found medication errors by staff.

The inspection was conducted as an unannounced complaint investigation visit following a complaint received on 2023-01-18 regarding reporting requirements and items posing danger accessible to residents.

The investigation found two allegations unsubstantiated due to lack of preponderance of evidence: failure to report incidents and dangerous items accessible to residents. However, the allegation of residents' personal rights violations was substantiated based on interviews revealing fear and intimidation by another resident, posing a potential health and safety risk.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Erik Gonzalez Campos. The complaint control number is 21-AS-20230118110739. The allegations included failure to report incidents and items posing danger accessible to residents, both unsubstantiated, and violation of residents' personal rights, substantiated. Appeal rights were provided.

The inspection was conducted due to a complaint alleging that staff spoke to a resident in an inappropriate manner.

The investigation found no preponderance of evidence to substantiate the allegation. Six residents interviewed, including the subject resident, denied the allegation. No deficiencies were cited during the inspection.

The allegation that staff spoke to a resident in an inappropriate manner was unsubstantiated after investigation.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 08/22/2022 regarding the facility's care practices.

All allegations including failure to follow resident's special diet, leaving a resident in his room during lunch, failure to provide nail care, and improper medication administration were investigated and found to be unsubstantiated due to lack of preponderance of evidence. No deficiencies were cited during the inspection.

The complaint investigation addressed multiple allegations: the facility not following a resident's special diet, leaving a resident in his room during lunch, not ensuring nail care, and not administering medication per physician's orders. Each allegation was found unsubstantiated after review of records, interviews, and observations.

The inspection was a case management follow-up visit conducted in response to several SOC 341 incident reports received by Community Care Licensing in late August 2022.

The inspection reviewed incidents involving resident-on-resident and resident-on-staff altercations in the memory care unit. The facility provided incident narratives and clarification, and has implemented measures to address resident behavior.

The inspection was an unannounced Post Licensing inspection conducted to evaluate the facility's compliance following licensing.

The facility was found to be in good repair, clean, and compliant with safety and care standards. No deficiencies were cited during the inspection.

The inspection was an unannounced case management visit conducted regarding an SOC341 received by Community Care Licensing on 06/30/2022.

During the inspection, the Licensing Program Analyst interviewed staff and reviewed resident records. Follow-up notes concerning SOC341 are pending the Wellness Coordinator's return. Yearly resident assessments for memory care unit residents were discussed with the administrator.

The visit was conducted as a change of ownership evaluation and pre-licensing readiness assessment for the Residential Care Facility for the Elderly.

The applicant/administrator participated in a COMP II telephone interview verifying identity and understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and reporting.

The inspection was a pre-licensing unannounced visit conducted due to a change in ownership from Brookdale Napa and included a hospice waiver request with the new application.

The facility was found to be in compliance with all applicable regulations, with no deficiencies cited. The environment was safe, clean, and well-maintained, with proper staffing, emergency systems, and infection control measures observed.

The visit was conducted as an office evaluation related to a Change of Ownership application for the Residential Care Facility for the Elderly.

The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.