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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:38:27 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
10/29/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211029160831
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: 75DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bessy John, Care CoordinatorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff are not providing adequate supervision.
Facility has insufficient staffing.
INVESTIGATION FINDINGS:
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On 8/26/2022 at 9:00AM, 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 Care Coordinator, Bessy John and informed her the reason for the visit.

During the course of investigation, the Department and LPA conducted interviews with staff, residents, witnesses, and complainant. Resident’s physician’s report, care plan, care notes, photos, incident reports, medical records, and hospital discharge records were obtained and reviewed.

Staff are not providing adequate supervision.
Record review of R1's care plan dated 6/15/2021 indicated that R1 requires 2 person assist during transfer, bathing, and toileting. However, interview with staff revealed that R1 have not been getting 2 person assist. Staff stated that residents have complained about NOC shift caregivers are not responding to pendent calls for assistance. (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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 5
Control Number 15-AS-20211029160831
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: 08/26/2022
NARRATIVE
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Facility has insufficient staffing.
Interview with witnesses revealed that there's not enough staff at the facility. Interview with staff revealed that facility is short staff at times. Interview with residents revealed staff during NOC shift takes longer time or not at all when responding to pendent call.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is 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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/29/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211029160831

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: 75DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bessy John, Care CoordinatorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Resident had suspicious bruising.
Facility staff is not allowing the daughter to visit the resident.
INVESTIGATION FINDINGS:
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On 8/26/2022 at 9:00AM, 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 Care Coordinator, Bessy John and informed her the reason for the visit.

During the course of investigation, the Department and LPA conducted interviews with staff, residents, witnesses, and complainant. Resident’s physician’s report, care plan, care notes, photos, incident reports, medical records, hospital discharge records, and visitation policy were obtained and reviewed.

Resident had suspicious bruising.
According to R1’s ER medical records dated 10/8/2021, R1’s diagnosis was injury from fall, facial hematoma and contusion of right shoulder and upper arm. Interview with staff revealed that R1 had an unwitnessed fall and staff (S3) denied causing injuries to R1. Interview with R1 revealed no addition information of how the injuries were sustained. (Continue on LIC9099C...)
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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211029160831
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: 08/26/2022
NARRATIVE
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Facility staff is not allowing the daughter to visit the resident.
Interview with residents revealed that visitors were allowed to visit residents. Interview with witnesses revealed that they can visit residents, but would need to follow facility's visitation policy. Record review indicated that visitors are screened prior to visit and facility limits the number of visitors in one location. Due to the pandemic, facility has new visitation policy to reduce the spread of COVID-19 which limits the number of persons per visit and the time of visitation.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

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

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20211029160831
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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2022
Section Cited
CCR
87705(c)(5)(A)
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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidence by:
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Facility has agreed to conduct training for all staff to follow the resident's care plan and submit staff sign-in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not following the care plan which poses a potential health and safety risk to the persons in care.
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Type B
09/12/2022
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s...care needs as identified in his/her current appraisal. This requirement is not met as evidence by:
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Facility has agreed to create a comprehensive plan on insufficient staffing and submit a copy of plan and LIC500 to CCLD by POC date. Plan should include evaluating how many residents needs care, resident's level of care, and how many staff per shift per floor.
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Based on investigation, licensee did not comply with the section cited above by not having sufficient staffing 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: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5