015601083-2-2-2023-15-AS-KHOS-CPGUVY-20230228145556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 02/02/2023
Date Signed: 02/02/2023 05:09:05 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
12/15/2021 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20211215150203

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: 74	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Bessy John, Care Coordinator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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9

Facility did not issue refund to authorized representative.

INVESTIGATION FINDINGS:

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On 2/2/2023 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Care Coordinator, Bessy John and informed her the reason for the visit.

During the course of investigation, LPA interviewed 2 staff and complainant. Resident's admission agreement, correspondence with R1's POA, procedure on refunds, and care notes were obtained and reviewed. Interview with staff and complainant revealed that R1 moved into the facility on 10/4/2021 and moved out on 11/27/2021. R1's signed admission agreement states if a preadmission appraisal is performed and resident leaves within 60 days, then 60% of preadmission fee will be refunded.

Based on LPA's 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 LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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-20211215150203

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: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/17/2023 Section Cited CCR 87507(g)(5)(E)(2)(b)	1 2 3 4 5 6 7	Admission Agreements . A refund of at least 60 percent of the preadmission fee...shall be provided if the resident leaves the facility for any reason during the second month of residency.	1 2 3 4 5 6 7	Facility has agreed to contact R1 or responsible party and provide the correct refund for preadmission fee. Facility will submit proof of communication and self-certification to CCLD by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing refund of 60% of preadmission fee which poses a potential personal rights violation to the persons 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: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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