019201003-2-16-2024-15-AS-KHOS-D8CLJF-20240821084753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201003
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:19:37 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
02/12/2024 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240212143438

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: 18	DATE:	02/16/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Janice Gombio, Administrator Isabel Poderoso, Campus Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff did not ensure facility was free from pests

INVESTIGATION FINDINGS:

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On 2/16/2024 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPA met with Campus Director, Isabel Poderoso and informed her the reason for visit. Administrator, Janice Gombio arrived 30 minutes later.

During the investigation, LPA interviewed 4 residents, 2 staff, and complainant. LPA reviewed and obtained documents including pest inspection report and communication with doctors. LPA inspected the 5 residents' beds and mattresses and did not observe bed bugs or other insects. Pest inspection report completed on 1/18/2024 inspected the 5 resident's mattress, box spring, sheets, and surrounding area with no evidence of bed bugs or other insects discovered.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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