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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:18:50 AM


Document Has Been Signed on 07/21/2022 11:18 AM - 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: 72DATE:
07/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Dolly Rizvi, AdministratorTIME COMPLETED:
11:35 AM
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On 07/21/2022 at 10:20AM, Licensing Program Analysts (LPA) C. Fowler and L. Hall arrived and conducted an unannounced case management health & safety check and met with Dolly Rizvi, Executive Director (ED) and explained the purpose of the visit.

LPAs was screened at the front entrance with routine COVID-19 symptom checks done by staff. LPAs toured the facility with ED. LPAs observed facility had sufficient food supplies in the kitchen. Food supplies are ordered & delivered weekly on Monday and Thursday. LPAs also observed adequate supply of PPE in storage room located on the 1st floor.

Sufficient staffing was observed during visit. Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards. Facility is maintained at a comfortable temperature for the residents in care. LPAs observed residents at the common area appeared to be well groomed, neat and comfortable. Facility appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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