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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:16:59 PM


Document Has Been Signed on 06/08/2022 04:16 PM - It Cannot Be Edited

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:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:99CENSUS: 71DATE:
06/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dolly Rizvi, AdministratorTIME COMPLETED:
04:30 PM
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On 06/08/22 at 1:30PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of a Death Report dated on 06/02/22 submitted to CCLD regarding unknown cause of death. LPA explained the purpose of the visit with administrator Dolly Rizvi.

Administrator stated to LPA that subject resident has a history of acute posthemorrhagic anemia and had been in baseline until passed. LPA obtained resident's preplacement appraisal, appraisal/needs and services plan, physical therapy notes, care notes, and staff schedule to review. LPA also interviewed 2 staff (S1 & S2) during visit. Both staff stated that they have not noticed resident's health condition has been changed while in care.

Return to facility for further information maybe needed. Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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