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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/04/2022
Date Signed: 04/04/2022 06:57:27 PM

Substantiated


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
04/09/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200409134327
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: 73DATE:
04/04/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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Staff failed to address resident's diabetic needs
Staff failed to ensure resident is properly fed
INVESTIGATION FINDINGS:
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On 4/4/2022 at 3:30PM, 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, Dolly Rizvi and informed her the reason for visit.

During the course of investigation, LPA interviewed 5 residents, 3 staff, and complainant. LPA reviewed and obtained facility menu, diabetic menu, and 2 resident files including physician's report, care plan, blood sugar log, food intake log, and facility care notes.

R1's blood sugar level log revealed that R1's blood sugar level varied from each day and time. R1's blood sugar level was read at 55 and other days above 300. According to R1's physician's report dated 1/15/2020, R1 was on a carb controlled diet. However, R1's food intake log revealed that R1 was given sandwiches and/or banana as a bedtime snack.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20200409134327
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: 04/04/2022
NARRATIVE
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According to facility care notes, R1 was given sandwiches, yogurt, and diabetic juice at various meal/snack times. Facility's diabetic diet plan from nutritionist states meals should included 1/2 cup of carbohydrates, more meat and veggies, diabetic drink, and diabetic desserts (cake or fruit).

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/09/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200409134327

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: 73DATE:
04/04/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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Resident sustained a fall while in care
INVESTIGATION FINDINGS:
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On 4/4/2022 at 3:30PM, 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 Executive Director, Dolly Rizvi and informed her the reason for visit.

During the course of investigation, LPA interviewed 5 residents, 3 staff, and complainant. LPA reviewed and obtained 2 resident files including physician's report, care plan, facility care notes, and incident reports. Interview with staff revealed that R1 and R2 did not have falls during their time at the facility. LPA reviewed incident reports for the facility and did not observed incident reports regarding a fall for R1 or R2.

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. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20200409134327
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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Administrator has agreed to provide a plan to address the needs of current/future residents with diabetes and better help manage their blood sugar level. Administrator will submit plan to CCLD by POC date.
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Based on investigation, licensee failed to comply with the section cited above by not addressing R1's diabetic needs which poses a potential health and safety risk to the persons in care.
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Type B
04/15/2022
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by:
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Administrator has agreed to provide a detailed nutritional plan for diabetic residents and submit plan to CCLD by POC date.
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Based on investigation, licensee failed to comply with the section cited above by not following physician's order for carb controlled diet which poses a potential health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4