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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 10/03/2024
Date Signed: 10/03/2024 06:05:20 PM

Document Has Been Signed on 10/03/2024 06:05 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: 18DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Isabel Poderoso, Campus DirectorTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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On 10/3/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 9/19/2024. LPA met with Campus Director, Isabel Poderoso and explained the purpose of the visit.

Incident report dated 9/19/2024 revealed that staff observed resident (R1) was not at the facility. R1's room door was locked and staff observed R1's window screen was broken. Facility called 911 and R1 returned to the facility with police. R1's family and doctor was notified.

Interview with staff revealed that R1 exhibited behaviors in the morning of the incident including agitation, refusal of meals and medications, and restlessness.

During record review, LPA observed that physician's report dated 1/17/2024 stated that R1 cannot leave the facility unassisted.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 06:05 PM - It Cannot Be Edited


Created By: Grace Luk On 10/03/2024 at 05:40 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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision...that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidence by:
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Facility has agreed to create a new care plan for R1 to address wandering behaviors and submit documents to CCLD by POC date.
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Based on interview and record review, licensee did not comply with the section cited above by having a resident missing from the facility which poses a potential health and safety risk to the persons in care.
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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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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