Milan Villa Senior Living

Allegation investigated: Questionable death of resident.

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 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.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 15-AS-20241126153238

Allegation investigated: Staff did not conduct re-evaluation after resident's change in condition.

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 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. 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.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 15-AS-20250404142130

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jan 9, 2026

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: 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.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

On 11/14/2025 at 2:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Executive Director, Janice Gombio and informed her the reason for the visit. 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 -11 degree F while the refrigerator’s temperature was recorded at 36 degrees F. Hot water temperature was measured at 105.3 degrees F in a resident bathroom. Grab bars and non-skid mats were observed in the showers and toilets. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 1/20/2025. First Aid kit is complete. Last disaster drill was conducted on 10/20/2025. LPA reviewed 5 residents and 4 staff files starting at 3:00PM. Residents' and staff files were complete. Staff were fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medications during inspection. No deficiencies are being cited on this date. Exit interview conducted with Janice Gombio. A copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Neglect resulting resident's dehydration. Resident developed pressure injuries while in care.

On 3/19/2025 at 2:10PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Executive Director, Janice Gombio and Campus Director, Isabel Poderoso. LPA informed them the reason for visit. During the investigation, LPA interviewed 2 residents, 3 staff, witness, and complainant. LPA reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, care plan, discharge documents, hospice information, emergency information, care notes, and death report. Neglect resulting resident's dehydration. R1's care plan indicated staff to encourage R1 to drink adequate amounts of fluids throughout the day with meals and offer preferred beverages with medication administration. Interview with staff revealed that R1 was given water during meals. S2 stated that R1 was given fluids 3-4 times per shift. (Continue on LIC9099C...) Unsubstantiated Resident developed pressure injuries while in care. Interview with W1 revealed that R1 did not develop pressure injuries during the time R1 was on hospice care. Interview with staff revealed that R1 was repositioned every 2 hours. R1's home health notes indicated that R1 was high risk of pressure sore, but did not indicate that R1 had pressure sore. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Janice Gombio. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 15-AS-20240520151707

Type of visit: Case Management - Health Checks

On 11/27/2024 at 10:20am, Licensing Program Analysts (LPAs), L. Hall and D. Doidge arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint on 11/26/2024. LPA met with Isabel Poderoso, Campus Director, and explained the reason for the visit. Administrator, Janice Gambio, arrived at 10:53am. During the health and safety check, LPAs toured the facility including but not limited to common areas, kitchen, bathrooms, bedrooms and outdoor area. LPAs observed resident sitting in common area watching television, in bedrooms, and hallway. The facility is noted to be clean, in good repair, and residents in care appear to be safe. There is a minimum of 7-day non-perishables and 2-day perishables foods that is kept in the sister facility next door. There are no imminent health/safety concerns on today's date. No deficiencies were cited today. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 27, 2024

Type of visit: Required - 1 Year

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...) 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.the state’s words, verbatim · CDSS document, Nov 14, 2024

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 10/3/2024 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 9/19/2024. LPA met with Campus Director, Isabel Poderoso and explained the purpose of the visit. Incident report dated 9/19/2024 revealed that staff observed resident (R1) was not at the facility. R1's room door was locked and staff observed R1's window screen was broken. Facility called 911 and R1 returned to the facility with police. R1's family and doctor was notified. Interview with staff revealed that R1 exhibited behaviors in the morning of the incident including agitation, refusal of meals and medications, and restlessness. During record review, LPA observed that physician's report dated 1/17/2024 stated that R1 cannot leave the facility unassisted. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 18, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision...that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidence by: Based on interview and record review, licensee did not comply with the section cited above by having a resident missing from the facility which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Facility has agreed to create a new care plan for R1 to address wandering behaviors and submit documents to CCLD by POC date.

Allegation investigated: Staff did not ensure facility was free from pests

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 15-AS-20240212143438

Type of visit: Case Management - Other

On 2/16/2024 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso. While LPA was at the facility for another visit, LPA observed the following deficiency: At around 10:00AM, LPA observed unlocked medication and vitamins was left on top of medication cart while residents were walking around. There was no staff present near the medication cart. Staff came back a couple minutes later and stated incorrect medication and vitamins was given. LPA advised staff the medication and vitamins needs to be locked up and inaccessible to residents. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 17, 2024

Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having unlocked medication and vitamins which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: Administrator has agreed to re-train staff on centrally stored medication and submit training material and staff sign-in sheet to CCLD by POC date.

Type of visit: Required - 1 Year

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...) 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.the state’s words, verbatim · CDSS document, Nov 21, 2023

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.