019201003-3-19-2025-15-AS-HHUL-DFKLNV-20250409085459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201003
Report Date: 03/19/2025
Date Signed: 03/19/2025 05:21:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2024 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240520151707

FACILITY NAME:	MILAN VILLA SENIOR LIVING		FACILITY NUMBER:	019201003
ADMINISTRATOR:	GOMBIO, JANICE		FACILITY TYPE:	740
ADDRESS:	740 HOLMES STREET		TELEPHONE:	(925) 583-5777
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	24	CENSUS: 19	DATE:	03/19/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Janice Gombio, Executive Director Isabel Poderoso, Campus Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Neglect resulting resident's dehydration.
Resident developed pressure injuries while in care.

INVESTIGATION FINDINGS:

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On 3/19/2025 at 2:10PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Executive Director, Janice Gombio and Campus Director, Isabel Poderoso. LPA informed them the reason for visit.

During the investigation, LPA interviewed 2 residents, 3 staff, witness, and complainant. LPA reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, care plan, discharge documents, hospice information, emergency information, care notes, and death report.

Neglect resulting resident's dehydration.
R1's care plan indicated staff to encourage R1 to drink adequate amounts of fluids throughout the day with meals and offer preferred beverages with medication administration. Interview with staff revealed that R1 was given water during meals. S2 stated that R1 was given fluids 3-4 times per shift. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240520151707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2025

NARRATIVE

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Resident developed pressure injuries while in care.
Interview with W1 revealed that R1 did not develop pressure injuries during the time R1 was on hospice care. Interview with staff revealed that R1 was repositioned every 2 hours. R1's home health notes indicated that R1 was high risk of pressure sore, but did not indicate that R1 had pressure sore.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted with Janice Gombio. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025

LIC9099 (FAS) - (06/04)

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