Inn On Villa Lane, The

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure medications are dispensed as prescribed to residents.

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 medications are dispensed as prescribed to residents. Prior to receiving this complaint, LPA Florio received an incident report on 07/30/2025, stating S1 made a medication error on 07/20/2025 with Resident 1 (R1), which did not result in harm to the resident. The report states S1 was coached and medication administration and record keeping were reviewed. LPA Florio conducted 10-day complaint investigation visit on 08/22/2025 and obtained documents, made observations, and conducted interviews. Continued on LIC9099C... Substantiatedthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 21-AS-20250821122246

Allegation investigated: 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.

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... Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 21-AS-20250821122246

Allegation investigated: 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.

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 reviewethe state’s words, verbatim · CDSS document, Jul 9, 2025 · control 21-AS-20250321090748

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not call emergency services for residents in care Staff did not prevent residents from smoking inside the facility Staff did not prevent residents from sleeping on the facility floor Staff did not prevent residents from entering other resident rooms Staff did not prevent resident from interfering with resident's care needs

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Dorla Licausi, reviewed records and interviewed staff. Based on records reviewed, LPA was not able to find evidence so support the allegations listed above. Records reviewed showed the facility contacted emergency services when residents are in need and basic first aid is provided when emergency services are not required. Based on interviews conducted and records reviewed, the facility has a strict no smoking indoor policy. Residents, however, are able to make decisions and not follow the policy. When smoking indoors is observed, staff remind residents of the risk and request they use the outdoor smoking areas. Based on records reviewed, residents have been found sleeping in areas other than their rooms. Records show when a resident is found sleeping in public areas, they are checked on and asthe state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20241211154024

Allegation investigated: Staff did not prevent resident from distributing marijuana products to residents in care Residents have access to centrally stored medications Staff are not able to provide adequate supervision to residents in care

At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Dorla Licausi, reviewed records and interviewed staff. Based on records reviewed, LPA was not able to find evidence so support the allegations listed above. Residents are allowed to leave the facility when they choose and to utilize recreational marijuana. LPA was not able to find evidence that residents were distributing marijuana products inside the facility. Based on records reviewed, there are many levels of care provided at the facility. Several residents are able to store and manage their own medications. Medications are secured in a locked drawer or when they leave their rooms by locking the door. LPA has made numerous visits to this facility and found the medication room to be secured when not occupied by staff. LPA conducted a review of staff schedules and found the facility is withinthe state’s words, verbatim · CDSS document, Apr 1, 2025 · control 21-AS-20250123145755

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff arranged for a resident to have another resident assist them while in care.

Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that facility staff made arrangements for Resident (R1) to assist another Resident(R2) by remaining in R2's room at night to remind R2 to call for assistance when needed. Through statements and document reviews, the following determinations are made: R1, R2, the Administrator and Nurse Consultant state that R1 volunteered to assist R2, who is a close friend, and that the facility staff have not requested or required R1 to provide any care or assistance to R2; There is no record indicating that the Physician for R2 has ordered night time supervision of R2 in excess of what is normally provided by staff for all residents in care. R1 and R2 state that the presence of R1 in R2's room at night is an informal arrangement which developed out of a friendship, was purely voluntary, and promulgated between themselves. Although the allegation may be true, based on stthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 21-AS-20240417163154

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mismanaging residents medication

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with Executive Director Dorla Licausi, reviewed records and interviewed staff. Based on records reviewed, the facility did not mismanage residents medication. LPA observed evidence the facility was in communication with the physician regarding refills and the delay was due to the physician not repsonding in a timely manner. Resident did not miss any of their prescribed doses and the medication was administered as directed. LPA received copies of documents. This agency has investigated the above allegation. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Oct 23, 2023 · control 21-AS-20231020094143

Allegation investigated: MEDICATIONS ARE NOT BEING PROVIDED AS ORDERED SPECIAL DIET, INCLUDING LIQUIDS, ARE NOT BEING PROVIDED AS ORDERED

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/11/23 at approximately 10:00am, LPA met with Interim Administrator Kim Alsup, and Dylan Nunn, Resident Service Directorr, LVN. LPA reviewed resident (R1) records, including medical assessment, care plan, appraisal(s), medical documents, Dr.ordered special diet(s), and resident's prescription orders. LPA reviewed information provided to the Department regarding the allegations. LPA conducted interviews with staff (S1, S2, S3), and other interested party(s). The investigation revealed that R1 has a Dr's Order for all liquids to be given thickened/nectar thick due to difficulty swalowing, and for food to be provided in a chopped texture to the resident (at the time of the incidents). R1 has a Dr's Order for medications to be given to the resident in applesauce and provided with thickened liquids. Continued on LIC9099C... Substantiatedthe state’s words, verbatim · CDSS document, Sep 11, 2023 · control 21-AS-20230629171636