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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201003
Report Date: 12/19/2025
Date Signed: 12/19/2025 05:48:19 PM

Substantiated


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
04/04/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250404142130
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: 20DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Janice Gombio, Executive Director
Isabel Poderoso, Campus Director		TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not conduct re-evaluation after resident's change in condition.
INVESTIGATION FINDINGS:
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On 12/19/2025 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Campus Director, Isabel Poderoso and informed her the reason for visit. Executive Director, Janice Gombio arrived two hours later.

During the course of investigation, LPA interviewed residents, staff, witness, and complainants. LPA reviewed and obtained documents including LIC500, staff schedule, physician's report, care plan, emergency information, facility notes, communication logs, and incident reports.

After reviewing R1's file, LPA observed facility only had physician's report dated 2/28/2024 and care plan with most recent services initiated on 10/7/2024. Interview with staff (S1) revealed that R1's doctor was notified of R1's changes in condition. However, S1 stated that R1 did not have an updated physician's report and care plan completed. (Continue on LIC9099C...)
Substantiated
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)
Page: 1 of 5
Control Number 15-AS-20250404142130
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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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted with Janice Gombio. A copy of this report and appeal rights 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)
Page: 2 of 5
Control Number 15-AS-20250404142130
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
87463(a)
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Reappraisals. (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... This requirement is not met as evidence by:
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Executive Director (ED) has agreed to create a written plan to update care plans when residents have changes in condition. ED will submit plan 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 not updating reappraisal/care plan when R1 had a change in condition 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/04/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250404142130

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: 20DATE:
12/19/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Janice Gombio, Executive Director
Isabel Poderoso, Campus Director		TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
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3
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5
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9
Staff did not provide supervision to residents in care.
INVESTIGATION FINDINGS:
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On 12/19/2025 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Campus Director, Isabel Poderoso and informed her the reason for visit. Executive Director, Janice Gombio arrived two hours later.

During the course of investigation, LPA interviewed residents, staff, witness, and complainants. LPA reviewed and obtained documents including LIC500, staff schedule, physician's report, care plan, emergency information, facility notes, communication logs, and incident reports.

Facility staff schedule indicated there was at least 2 staff on duty for each shift. Interview with staff revealed R1 was check on regularly and often as R1 is a fall risk with wandering behaviors. S3 stated that when R1 fell in 11/2/2024, S3 checked on R1 about an hour prior to incident. Facility notes indicated that R1 was check every 2-3 hours. (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)
Page: 4 of 5
Control Number 15-AS-20250404142130
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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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 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)
Page: 5 of 5