Milan Villa Senior Living

On 11/18/2021 at 2:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso. Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, hand washing stations, kitchen, and common areas. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks and bathrooms were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed COVID-19 test results for staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient. The following deficiency was observed during the visit: -Approximately at 3:15pm, LPA observed the housekeeping door was unlocked and cleaning supplies were observed in the housekeeping room. Staff fixed the lock on the door and was in operating condition prior to end of inspection. LPA verified that the door was locked. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 11/14/2024 at 9:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Honey Yang and informed her the reason for the visit. Administrator, Janice Gombio arrived an hour later. 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 -10 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Hot water temperature was measured at 106.5 degrees F in the hallway bathroom. Grab bars and non-skid mats were observed. There were adequate lights in each 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 1/4/2024. Indoor and outdoor passages were free of obstruction. LPA reviewed 5 residents and 4 staff files starting at 10:55AM. LPA reviewed a sample of resident's medications. LPA interviewed 3 staff during inspection. At 10:30AM, LPA reviewed Guardian system and observed S5 is not fingerprint cleared. At 11:30AM, LPA observed R2 does not have current medical assessment on file. At 11:40AM, LPA observed R5 does not have admission agreement on file. At 1:30PM, LPA observed unlocked cough medication in a resident's room. Staff locked up the medication during inspection. (Continue on LIC809C...) 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 2:30PM, LPA observed R3's Docusate Sodium was not given according to doctor's order. R3 had doctor's order for Docusate 250mg daily at bedtime and Docusate 100mg as needed. Both orders were not discontinued. However, LPA observed on R3's MAR that Docusate was a PRN (as needed). Staff stated that R3 have not been taking Docusate daily. At 4:30PM, LPA R4's medical assessment stated that R4 is bedridden. R4 is not currently receiving hospice care. Staff stated that R4 needs assistance with turning and repositioning. Facility does not have a bedridden fire clearance. Civil penalty of $500 is being assessed. Facility was given technical violations and reports will be provided. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report, civil penalties, and appeal rights were provided.

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...) 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.

On 11/18/2022 at 9:05AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct an Infection Control Inspection. LPAs met with Admission and Marketing Director, Bibi Barase. Upon entry, LPAs filled out visitor log. LPAs observed hand sanitizer at screening station. LPAs toured facility including but not limited to bedrooms, bathrooms, shower room, laundry room, kitchen, and common areas. LPAs observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All sinks and bathrooms were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms. First aid kit was complete and fire extinguisher was last serviced on 2/10/2022. During record review, LPAs observed visitors log and temperature log for both residents and staff. LPAs observed facility has a copy of Mitigation Plan on file. Staff were FIT tested and LPAs reviewed completion certificates. LPAs observed PPEs, food supplies, and paper supplies are sufficient. At 9:30AM, LPAs observed the housekeeping door and laundry room door were unlocked. The rooms had unlocked cleaning supplies and laundry detergents accessible. Staff locked up the rooms during inspection. At 9:45AM, LPAs observed facility only had one available shower room for 16 residents. The other two shower rooms were filled with storage items when staff opened the door. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.