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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 08/21/2020
Date Signed: 08/21/2020 04:58:52 PM

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:MARYMOUNT VILLA RETIREMENT CENTERFACILITY NUMBER:
015601083
ADMINISTRATOR:JASMINE SEABOURNEFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:99CENSUS: 75DATE:
08/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:28 PM
MET WITH:Kimberly LemusTIME COMPLETED:
04:45 PM
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On 08/21/20 at 4:28 PM, Licensing Program Analyst (LPA) I. Castro called to conduct a health and safety check via tele-visit as a result of the department receiving a priority 2 complaint. LPA explained the face time tele-visit with the facility business manager who was physically unavailable to sign this report due to COVID-19 shelter in place order issued by the CA governor on March 17,2020.

During health and safety check, LPA observed rooms in the following area: floors 1, 2, 3, and 5. The fourth floor is reserved for COVID-19 positive residents. Facility is clean and no obstruction in the hallway or common area.

LPA toured the facility with facility business manager including, but not limited to bedrooms, bathrooms, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. Fire extinguisher last checked on 07/09/2020.

No deficiencies were cited during this health and safety check.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 622-2610
LICENSING EVALUATOR NAME: Isaac CastroTELEPHONE: (510) 622-2642
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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