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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 02/03/2023
Date Signed: 02/03/2023 03:53:38 PM

Unsubstantiated


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
01/13/2021 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20210113112850
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: 74DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bessy John, Care Coordinator TIME COMPLETED:
04:05 PM
ALLEGATION(S):
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9
Facility not observing changes in resident's health.
Staff did not notify responsible party of residents change in health
Staff did not check the resident every 2 hours
INVESTIGATION FINDINGS:
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5
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13
On 2/3/2023 at 12:45PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct a complaint investigation to the allegations above. LPA met with Care Coordinator, Bessy John and informed her the reason for the visit.

During the course of the investigation, LPA K. Nguyen obtained information, reviewed records, collected documents, and interviewed staff. It was alleged facility not observing changes in resident’s health and staff did not check the resident every 2 hours. However, based on interview with 4 staff on 2/3/2023, 4 of 4 staff stated they conduct routine checks at every 1 to 2 hours during their shift and document what they observe on the caregiver notes. Record review of caregiver notes from October of 2019 through January of 2020 indicated no changes in resident’s condition.

Report continue on LIC 9099C...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 2
Control Number 15-AS-20210113112850
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: 02/03/2023
NARRATIVE
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It was alleged staff did not notify responsible party of residents change in health. However, during record review, LPAs observed an email communication between S5 and S6 indicating that they are communicating any concern regarding R1 with R1’s responsible party. In addition, record review of internal incident report revealed that the facility notified R1’s responsible party on 12/27/2020 of R1’s fall.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2