019201003-11-21-2023-15-AS-GLUK-CXT5MQ-20231121190507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201003
Report Date: 11/21/2023
Date Signed: 11/21/2023 07:05:18 PM

Document Has Been Signed on 11/21/2023 07:05 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 LIVING		FACILITY NUMBER:	019201003
ADMINISTRATOR:	UNNKNOWN		FACILITY TYPE:	740
ADDRESS:	740 HOLMES STREET		TELEPHONE:	(925) 583-5777
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	24	CENSUS: 15	DATE:	11/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Janice Gombio, Administrator Isabel Poderoso, Campus Director		TIME COMPLETED:	07:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/21/2023 at 11:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso. The facility’s fire clearance was approved for 24 non-ambulatory residents of which 12 residents may be under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Freezer’s temperature was registered at -20 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Hot water temperature was measured at 108 degrees F in a resident's bathroom. Grab bars and non-skid mats were observed. There were adequate lights in each room. Centrally stored medications were locked in medication carts located outside the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/23/2023. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 10/16/2023. LPA reviewed 5 resident and 3 staff files starting at 12:45PM. LPA interviewed 3 residents starting at 11:42AM. LPA reviewed a sample of resident's medications starting at 4:00PM. LPA interviewed 3 staff starting at 4:40PM. At 11:30AM, LPA observed facility does not have one week of non-perishable food supplies available. LPA was informed that non-perishable food supplies are kept at a different location. At 1:15PM, LPA observed R1 does not have current medical assessment and R1-R5 does not have current reappraisal needs and service plans on file. (Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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 6

Document Has Been Signed on 11/21/2023 07:05 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current annual training for S3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain current annual training for S3 and submit training certificates to CCLD by POC date.

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having TB test or chest x-ray results for two residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain R3 and R4's TB test and chest x-ray results and submit a copy to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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
	VISIT DATE: 11/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At 1:30PM, LPA observed R3 and R4 does not have TB test or chest x-ray results on file during record review.

At 2:00PM, LPA observed S3 does not have current annual training completed.
At 4:30PM, LPA observed R2 does not have the following medications at the facility including: Hydrocodone Acetaminophen 325mg, Robitussin Peak Cold DM syrup, and Carbamide Peroxide Solution. LPA observed R2 does not have discontinue orders for the three medications.

At 5:10PM, LPA observed on Guardian that S4 was not fingerprint cleared. S4's status on Guardian was "closed - incomplete application". LPA observed that S4 left the facility during visit. Civil penalty of $500 is being assessed.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 11/21/2023 07:05 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having fingerprint clearance for S4 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator asked S4 to leave the facility during inspection. Administrator has agreed that S4 will not come back to the facility until fingerprint clear has been completed. Administrator has agreed to follow up with Guardian and submit an update of S4's clearance status to CCLD by POC date. Civil penalty of $500 is being assessed.

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having R2's prescribed medications available which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to either obtained the three medications or to get a discontinued order for the three medications. Administrator will submit picture or document proof to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 11/21/2023 07:05 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not having one week of nonperishable foods which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/28/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to purchase additional nonperishable foods or purchase emergency food for the facility. Administrator will submit receipt to CCLD by POC date.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for R1 and current reappraisal for five residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator has agreed to obtain current medical assessment for R1 and reappraisals for R1-R5. Administrator will submit documents to CCLD by POC date.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6