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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 11/19/2020
Date Signed: 11/19/2020 12:11:24 PM

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:UNNKNOWNFACILITY TYPE:
740
ADDRESS:740 HOLMES STREETTELEPHONE:
(925) 285-4928
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:24CENSUS: 15DATE:
11/19/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Toby Tilford, Licensee
Maria Acaoili, Administrator
Isabel Poderosa, Campus Director
Janice Gombio, Administrator in training		TIME COMPLETED:
12:00 PM
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On 11/19/2020 at 10:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Pre-Licensing inspection via Zoom due to shelter in place directed by the Governor. LPA spoke with Toby Tilford (Licensee), Maria Agcaoili (Administrator), Isabel Poderosa (Campus Director), Janice Gombio (Administrator in training). The facility's fire clearance was approved for 24 non-ambulatory residents.

During the Tele-Inspection, LPA toured facility with Licensee/Administrator including but not limited to resident's bedrooms, bathrooms, common areas, kitchen, laundry room, activity room and outdoor area. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Resident's bathrooms were equipped with grab bars and showers have non-skid mats. LPA observed lighting in all rooms. LPA observed facility had a 7-day of non-perishable and 2-day perishable food supplies. Facility has a medication cart located in the hallway which was locked during inspection. Smoke detectors are interconnected with sprinkler system. Carbon Monoxide detectors were observed in common areas. First aid kit is complete. Maintenance had check the hot water temperature this morning which was 107 degrees F. LPA advised Licensee that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 7/8/2020. Emergency disaster plan was completed on 5/29/2020.

LPA conducted Component III with Licensee, Administrator, Administrator in training and Campus Director during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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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