MILAN VILLA SENIOR LIVING

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Jan 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by having a bedridden resident without a bedridden fire clearance which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Administrator has agreed to notify the fire department. Administrator will submit proof of notification to fire department, LIC200, and updated facility sketch to CCLD by POC date. Civil penalty of $500 is being assessed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by having uncleared staff at the facility which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction S5 left the facility during inspection. Administrator stated that S5 has recently resigned and will not be working at the facility. Civil penalty of $100 is being assessed.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having admission agreement for R5 which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction Administrator has agreed to obtain a copy of R5's admission agreement and submit a copy to CCLD by POC date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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 Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for R2 which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction Administrator has agreed to obtain current medical assessment for R2 and submit a copy to CCLD by POC date. Civil penalty of $250 is being assessed for a repeat violation.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having unlocked medication in resident's room which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Staff locked up the cough medication during inspection. Deficiency cleared. Civil penalty of $250 is being assessed for a repeat violation.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(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 Based on interview and record review, the licensee did not comply with the section cited above by not administering R3's medication per doctor's orders which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Staff was able to clarity R3's docusate sodium order and obtained a new order for R3's medication. Deficiency cleared. Civil penalty of $250 is being assessed for a repeat violation.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Oct 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official 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.

Deadline recorded: Feb 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/15/2023 Plan of Correction Administrator has agreed to obtain current annual training for S3 and submit training certificates to CCLD by POC date.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/15/2023 Plan of Correction 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.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction 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.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction 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.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 11/28/2023 Plan of Correction Administrator has agreed to purchase additional nonperishable foods or purchase emergency food for the facility. Administrator will submit receipt to CCLD by POC date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 12/15/2023 Plan of Correction Administrator has agreed to obtain current medical assessment for R1 and reappraisals for R1-R5. Administrator will submit documents to CCLD by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies and laundry detergent which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/19/2022 Plan of Correction Staff locked up the laundry and cleaning supply room during inspection. Deficiency cleared

Official classification

Type B

Official code

87307(b)(2)

Regulation authority

CCR

What the official deficiency says

(b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following: (2) At least one bathtub or shower for each ten (10) persons, which includes residents, family and live-in personnel. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by only having one shower for 16 residents which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/25/2022 Plan of Correction Facility has agreed to clear out the storage items in the two shower rooms and have them available for residents. Administrator will submit picture proof to CCLD by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supplies which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/19/2021 Plan of Correction Administrator had maintenance fix the lock on the housekeeping door. LPA verified that the lock was in operating condition. Deficiency cleared during inspection.