015601083-12-20-2022-15-AS-KHOS-CMJQJ6-20221228111212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:16:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
06/29/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220629163805

FACILITY NAME:	MARYMOUNT VILLA RETIREMENT CENTER		FACILITY NUMBER:	015601083
ADMINISTRATOR:	DOLLY RIZVI		FACILITY TYPE:	740
ADDRESS:	345 DAVIS STREET		TELEPHONE:	(510) 895-5007
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	99	CENSUS: 72	DATE:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Dolly Rizvi, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident was served spoiled food
Facility mismanaged resident's medication
Facility failed to provide adequate assistance with dressing

INVESTIGATION FINDINGS:

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On 12/20/22 at 3:05pm, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and delivered investigation findings. LPA met with Administrator and explained the purpose of the visit.

Allegation: Resident was served spoiled food-Unsubstantiated
The Department has investigated this allegation and per interviews and records review found that spoiled food was not observed by 7 staff and 6 residents who were interviewed. Based on the work schedule in subject time period, no Asian male caregiver was identified during the course of investigation.

Continue LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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-20220629163805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER	FACILITY NUMBER: 015601083
	VISIT DATE: 12/20/2022

NARRATIVE

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Allegation: Facility mismanaged resident's medication-Unsubstantiated
The Department has investigated this allegation and per interviews and records review found that inaccurate count medications was not noticed by staff S6 and S7, and no additional information regarding miscounted medication was found. Based on R1’s Medication Administration Records (MAR), most of medications were given to R1 except Haldol 2mg/ml when R1 was discharged. S6 stated that Haldol was finished and required to be refiled. W1, W2 and W4 stated that refilling medications was responsible by resident’s POA or conservator.

Allegation: Facility failed to provide adequate assistance with dressing-Unsubstantiated
The Department has investigated this allegation and per interviews and records review found that staff S4 and S5 who were R1’s caregivers denied not to provide adequate assistance with dressing. Both caregivers stated that R1 knew what clothes R1 liked to wear and what type of hair R1 liked to be made. R1 always had her dressing including bra, compress socks, and shoes on outings. No other witness and additional information of alleged violation occurred in subject time period was found.

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

No deficiencies cited. Exit interview conducted the care coordinator, and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC9099 (FAS) - (06/04)

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