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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:51:45 AM


Document Has Been Signed on 09/06/2022 11:51 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: 71DATE:
09/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
12:10 PM
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On 09/06/22 at 10:30AM, Licensing Program Analysts (LPAs) D Panlilio and M. Malik arrived unannounced to conduct a case management health & safety check and met with Executive Director (ED) and explained the purpose of the visit.

LPAs were 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.

During visit, LPAs observed 14 staff wearing face masks assisting 33 residents with various activities such as having late breakfast, singing in the activities rooms in the 1st, 2nd and 3rd floors and assisting some residents go back to their bedrooms. LPAs observed freezer temperatures were at 0 deg F and refrigerator temperatures were at 40 deg F. LPAs observed sufficient food supplies (2 day perishables and 7 day non perishables) in the kitchen area . LPAs also observed adequate supply of PPEs stored in a cabinet on the 1st floor. Medications were observed stored in the medication room which is always staffed and locked. Toxic chemicals were observed stored and locked in the 3rd floor Wellness Room cabinets. Pathways and hallways were observed free of obstruction and fire hazards.

Sufficient staffing was observed during visit. Facility is maintained at a comfortable temperature of 74 deg F for 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) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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