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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:30:09 AM


Document Has Been Signed on 11/18/2022 11:30 AM - 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:UNNKNOWNFACILITY TYPE:
740
ADDRESS:740 HOLMES STREETTELEPHONE:
(925) 583-5777
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:24CENSUS: 16DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Bibi Barase, Admission and Marketing DirectorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 11/18/2022 at 9:05AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct an Infection Control Inspection. LPAs met with Admission and Marketing Director, Bibi Barase.

Upon entry, LPAs filled out visitor log. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, shower room, laundry room, kitchen, and common areas. LPAs observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks and bathrooms were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. First aid kit was complete and fire extinguisher was last serviced on 2/10/2022.

During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. Staff were FIT tested and LPAs reviewed completion certificates. LPAs observed PPEs, food supplies, and paper supplies are sufficient.

At 9:30AM, LPAs observed the housekeeping door and laundry room door were unlocked. The rooms had unlocked cleaning supplies and laundry detergents accessible. Staff locked up the rooms during inspection.

At 9:45AM, LPAs observed facility only had one available shower room for 16 residents. The other two shower rooms were filled with storage items when staff opened the door.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 11/18/2022 11:30 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning supplies and laundry detergent which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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Staff locked up the laundry and cleaning supply room during inspection.

Deficiency cleared
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/18/2022 11:30 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(b)(2)
(b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following:
(2) At least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel.

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 only having one shower for 16 residents which poses a potential health and safety risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
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Facility has agreed to clear out the storage items in the two shower rooms and have them available for residents. Administrator will submit picture proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3