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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 12/07/2021
Date Signed: 12/07/2021 03:21:58 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
08/06/2020 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200806155256
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: 68DATE:
12/07/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility does not provide a safe and healthful environment for the resident.
INVESTIGATION FINDINGS:
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On 12/7/2021 starting at 1:20 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Executive Director, Dolly Rizvi and explained the purpose of the visit.

During the complaint of investigation, LPA obtained information, interviewed Executive Director and resident. It was alleged facility does not provide a safe and healthful environment for the resident. LPA discovered during an interview with R1 on 12/7/2021 that R2 was going into R1's apartment at night. R1 was unable to provide LPA an exact date of when facility was notified of the issue. Based on document obtained, once facility was made aware of the issue, facility moved the R2 to a different room. LPA Jacob Williams received a document on 3/17/2021 which indicates that R1's family member notified facility of the issue on 8/21/2020 and R2 was moved to a different room on 8/26/2020.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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 2
Control Number 15-AS-20200806155256
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: 12/07/2021
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.



SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2