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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 11/14/2024
Date Signed: 11/14/2024 06:40:58 PM

Document Has Been Signed on 11/14/2024 06:40 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MILAN VILLA SENIOR LIVINGFACILITY NUMBER:
019201003
ADMINISTRATOR/
DIRECTOR:		GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:740 HOLMES STREETTELEPHONE:
(925) 583-5777
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 24CENSUS: 17DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Janice Gombio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 11/14/2024 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Honey Yang and informed her the reason for the visit. Administrator, Janice Gombio arrived an hour later.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Freezer’s temperature was registered at -10 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Hot water temperature was measured at 106.5 degrees F in the hallway bathroom. Grab bars and non-skid mats were observed. There were adequate lights in each room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/4/2024. Indoor and outdoor passages were free of obstruction.

LPA reviewed 5 residents and 4 staff files starting at 10:55AM. LPA reviewed a sample of resident's medications. LPA interviewed 3 staff during inspection.

At 10:30AM, LPA reviewed Guardian system and observed S5 is not fingerprint cleared.

At 11:30AM, LPA observed R2 does not have current medical assessment on file.

At 11:40AM, LPA observed R5 does not have admission agreement on file.

At 1:30PM, LPA observed unlocked cough medication in a resident's room. Staff locked up the medication during inspection.
(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MILAN VILLA SENIOR LIVING
FACILITY NUMBER: 019201003
VISIT DATE: 11/14/2024
NARRATIVE
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At 2:30PM, LPA observed R3's Docusate Sodium was not given according to doctor's order. R3 had doctor's order for Docusate 250mg daily at bedtime and Docusate 100mg as needed. Both orders were not discontinued. However, LPA observed on R3's MAR that Docusate was a PRN (as needed). Staff stated that R3 have not been taking Docusate daily.

At 4:30PM, LPA R4's medical assessment stated that R4 is bedridden. R4 is not currently receiving hospice care. Staff stated that R4 needs assistance with turning and repositioning. Facility does not have a bedridden fire clearance.
Civil penalty of $500 is being assessed.

Facility was given technical violations and reports will be provided.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalties, and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/14/2024 06:40 PM - It Cannot Be Edited


Created By: Grace Luk On 11/14/2024 at 05:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MILAN VILLA SENIOR LIVING
FACILITY NUMBER: 019201003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by having a bedridden resident without a bedridden fire clearance which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Administrator has agreed to notify the fire department. Administrator will submit proof of notification to fire department, LIC200, and updated facility sketch to CCLD by POC date.
Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87411(g)(1)
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having uncleared staff at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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S5 left the facility during inspection. Administrator stated that S5 has recently resigned and will not be working at the facility.
Civil penalty of $100 is being assessed.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/14/2024 06:40 PM - It Cannot Be Edited


Created By: Grace Luk On 11/14/2024 at 05:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MILAN VILLA SENIOR LIVING
FACILITY NUMBER: 019201003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having admission agreement for R5 which poses a potential health and safety risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Administrator has agreed to obtain a copy of R5's admission agreement and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for R2 which poses a potential health and safety risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessment for R2 and submit a copy to CCLD by POC date.
Civil penalty of $250 is being assessed for a repeat violation.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/14/2024 06:40 PM - It Cannot Be Edited


Created By: Grace Luk On 11/14/2024 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MILAN VILLA SENIOR LIVING
FACILITY NUMBER: 019201003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medication in resident's room which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Staff locked up the cough medication during inspection.
Deficiency cleared.
Civil penalty of $250 is being assessed for a repeat violation.
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not administering R3's medication per doctor's orders which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Staff was able to clarity R3's docusate sodium order and obtained a new order for R3's medication. Deficiency cleared.
Civil penalty of $250 is being assessed for a repeat violation.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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