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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:20:32 PM


Document Has Been Signed on 02/16/2024 01:20 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:GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:740 HOLMES STREETTELEPHONE:
(925) 583-5777
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:24CENSUS: 18DATE:
02/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Janice Gombio, Administrator
Isabel Poderoso, Campus Director		TIME COMPLETED:
01:40 PM
NARRATIVE
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On 2/16/2024 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso.

While LPA was at the facility for another visit, LPA observed the following deficiency:

At around 10:00AM, LPA observed unlocked medication and vitamins was left on top of medication cart while residents were walking around. There was no staff present near the medication cart. Staff came back a couple minutes later and stated incorrect medication and vitamins was given. LPA advised staff the medication and vitamins needs to be locked up and inaccessible to residents.

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 penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 02/16/2024 01:20 PM - 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: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
This requirement is not met as evidence by:
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Administrator has agreed to re-train staff on centrally stored medication and submit training material and staff sign-in sheet to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by having unlocked medication and vitamins which poses an immediate 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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