015601083-4-22-2021-15-AS-KHOS-C2HM9F-20210428092442

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/22/2021
Date Signed: 04/22/2021 03:30:25 PM

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
11/22/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191122080505

FACILITY NAME:	MARYMOUNT VILLA RETIREMENT CENTER		FACILITY NUMBER:	015601083
ADMINISTRATOR:	JASMINE SEABOURNE		FACILITY TYPE:	740
ADDRESS:	345 DAVIS STREET		TELEPHONE:	(510) 895-5007
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	99	CENSUS: 46	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Dolly Rizvi, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Resident's personal care needs are not being met by the facility

INVESTIGATION FINDINGS:

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On 4/22/2021 at 3:00PM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegation. LPA G. Luk spoke with Administrator, Dolly Rizvi and explained reason for the tele-visit. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed staff, resident, home health nurse, and complainant. LPA reviewed resident's file including physician's report, care plan, care notes. Interview with H1 revealed that wound care for R1 should be done at least 2x daily. However, R1 stated that wound care has been done once a day for about 2 weeks. LPA reviewed care notes between late October 2019 through early November 2019 which revealed that wound care was done only once daily during AM shift.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of report and appeal rights will be emailed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20191122080505

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: 04/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/30/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator has agreed to conduct training for all staff on wound care and following doctor's orders. Administrator will submit staff sign in sheet and training materials to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not following wound care instructions which poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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