015601083-4-19-2022-15-AS-YFLS-CEPW5N-20220523165925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:32:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200820103930

FACILITY NAME:	MARYMOUNT VILLA RETIREMENT CENTER		FACILITY NUMBER:	015601083
ADMINISTRATOR:	JASMINE SEABOURNE		FACILITY TYPE:	740
ADDRESS:	345 DAVIS STREET		TELEPHONE:	(510) 895-5007
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	99	CENSUS: 62	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Dolly Rizvi, Executive Director		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Facility not following physician's medical orders
Facility not observing changes in resident's health.
Staff not treating resident with dignity.

INVESTIGATION FINDINGS:

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On 4/19/22 at 1:00pm, Licensing Program Analysts (LPAs) C. LIn and K. Nguyen arrived unannounced to deliver findings on the above allegations. LPA met with Executive Director Dolly Rizvi and explained the purpose of visit.

During the course of investigation, the following steps were undertaken:
1. On 8/21/2020, LPA Isaac Castro and AGPA Jeremy Fong initiated 10-day investigation via televisit due to the shelter in place directive of the Governor related to Covid 19 epidemic.
2. On 8/21/2020, LPA Castro and AGPA Fong conducted pre investigation.
3. On 10/14/2021, complaint was reassigned to LPA Luisa Fontanilla.
4. On 11/24/2021, LPA L. Fontanilla interviewed Executive Director Dolly Rizvi.
5. On 4/12/2022, LPA Fontanilla interviewed Receptionist, Nurse and 4 caregivers and reviewed records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200820103930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 015601083
	VISIT DATE: 04/19/2022

NARRATIVE

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Resident sustained pressure injuries while in care. - UNSUBSTANTIATED
LPA Luisa Fontanilla interviewed Executive Director, one nurse, one Receptionist and 4 caregivers. LVN and caregivers interviewed state they do not recall R1 developing pressure injuries while at the facility. Staff state they were applying barrier cream on R1’s buttock, putting pillow under R1’s legs to get them elevated, check and change diaper/reposition every one-two hours. A review of R1’s Physician’s Report and medical records indicate R1 has a history of ulcer of right heel and ulcer of buttock. On 9/17/2019, R1 had an office visit with Podiatry Doctor for Ulcer of Right Heel. R1 moved to the facility on 10/28/2019.

Facility not following physician's medical orders. – UNSUBSTANTIATED
Reporting Party alleged staff were not following R1’s doctor order to change R1 every two hours instead of every 4 hours.
On 4/12/2022, LPA L. Fontanilla interviewed caregivers and nurse. Staff interviewed state that they reposition, check/change R1’s diaper if needed at least every 1-2 hours. And that staff apply skin barrier ointment on R1’s buttocks to prevent pressure sores.

Facility not observing changes in resident's health. - UNSUBSTANTIATED
RP alleged that during RP’s last visit with R1 prior to lockdown, RP observed R1 shaking due to problem urinating and had to instruct staff to send R1 to the hospital. However, RP does not remember the date of the incident.
Based on records reviewed, R1 complained of pain with urine on 7/31/2020. Facility notified the doctor and R1 was prescribed antibiotic for 5 days. Treatment ended on 8/10/2020. On 8/21/2020, R1 complained of burning to touch and with urination. R1’s doctor was notified and urinalysis was ordered. R1’s Physician’s Report indicate R1 is able to communicate needs.

Staff not treating resident with dignity. - UNSUBSTANTIATED
RP alleged that staff throw away left over foods brought for R1 by family. Based on caregiver notes dated 8/20/2020, R1 was served left over foods brought by R1’s family.

Based on records reviewed and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted.

Exit interview was conducted and a copy of this report was provided to Executive Director.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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