019201003-12-19-2025-15-AS-HHUL-DPV2JN-20251230162633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201003
Report Date: 12/19/2025
Date Signed: 12/19/2025 05:44:54 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
11/26/2024 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20241126153238

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: 20	DATE:	12/19/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Janice Gombio, Executive Director Isabel Poderoso, Campus Director		TIME COMPLETED:	10:30 PM

ALLEGATION(S):

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Questionable death of resident.

INVESTIGATION FINDINGS:

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On 12/19/2025 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegation above. LPA met with Campus Director, Isabel Poderoso and explained to her the reason for the visit. Executive Director, Janice Gombio arrived two hours later.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and complainant. Resident’s physician's report, preplacement appraisal, appraisal needs and service plan, emergency information, admission agreement, incident reports, medical records, death certificate, coroner’s report, and ambulance report were obtained and reviewed.

Incident report indicated that on 11/2/2024 staff heard a noise in resident’s (R1) room and found R1 on the floor laying on her right side. Staff (S2) observed R1 with facial grimacing and unable to move extremities, which S2 called 911 and R1 was transported to the hospital. R1’s medical record revealed that R1 sustained a left femoral neck fracture and had hip hemiarthroplasty procedure on 11/4/2024. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

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-20241126153238

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: 12/19/2025

NARRATIVE

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R1 passed away on 11/7/2024 as a result of complications of the procedure.

Interview with witness indicated during the 911 call staff (S2) stated R1 fell as a result of being pulled or pushed by another resident (R2). However, interview with staff (S2 and S3) revealed that they did not know how R1 fell. S2 stated he did not know why he reported during the 911 call that R2 pulled or pushed R1 to the floor and R2 did not say that she pushed R1. S2 does not know how R1 ended up on the floor, but R2 reported that R1 had fallen. S3 stated R1 had a history of falls prior to the incident on 11/2/2024.

Interview with staff and residents revealed that R2 did not have a history of physical aggression towards residents or R1. Residents (R3 and R4) stated R1 would walk into other resident’s rooms and take their belongings. Staff (S2 and S3) stated R2 would get upset with R1, but R2 was only seen to be verbally aggressive towards R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

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

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

LIC9099 (FAS) - (06/04)

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