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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 03/07/2023
Date Signed: 03/08/2023 12:08:00 AM

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
10/27/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211027131428
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: 73DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility staff are not dispensing resident's medication as prescribed
Facility staff are not ensuring that resident is following a prescribed diet
INVESTIGATION FINDINGS:
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On 3/7/2023 at 11:30AM, 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 Executive Director (ED), Dolly Rizvi and informed her the reason for the visit.

During the course of investigation, LPA interviewed 6 residents, 5 staff, 2 witnesses, and complainant. Resident's transportation information, MAR, correspondence with doctor, medication list, care notes, diabetic diet, blood sugar log, and hospital discharge documents were obtained and reviewed.

Facility staff are not dispensing resident's medication as prescribed
LPA observed MAR for August, September, and October of 2021 had blank or "crossed out" on dates where the "initials" should be. Interview with staff revealed that "crossed out" maybe an indication medications ran out. When R1 was out or hospitalized, it was indicated on the MAR. However, those blank or "crossed out" spaces did not state that R1 was out or hospitalized. It was not indicated if medications were administered on those days. (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: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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 5
Control Number 15-AS-20211027131428
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: 03/07/2023
NARRATIVE
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Facility staff are not ensuring that resident is following a prescribed diet
R1's plan of care dated 6/21/2021 stated that R1 was on a renal and diabetic diet. Interview with staff revealed that diabetic diet limit carbs, more vegetables, less salt, and diabetic dessert. However, LPA observed R1's blood sugar log for October 2021 was in the high 300s with one day in the 500s. S4 stated that R1 does not keep to the diet and R1's doctor has been notified. After reviewing R1's file, LPA did not observed correspondence to doctor regarding R1 not adhering to renal and diabetic diet.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are 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: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20211027131428
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: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidence by:
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ED has agreed to retrain all staff on medication administration and medication documentation. ED will submit staff sign-in sheet and training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.
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Type B
03/24/2023
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by:
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ED has agreed to create a written plan to address modified diets for residents and procedures that staff should follow. ED will submit written plan to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not ensuring R1 is following specified diet 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: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
10/27/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211027131428

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: 73DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner
Facility staff are not arranging transportation for resident's medical appointment.
INVESTIGATION FINDINGS:
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On 3/7/2023 at 11:30AM, 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 Executive Director (ED), Dolly Rizvi and informed her the reason for the visit.

During the course of investigation, LPA interviewed 6 residents, 5 staff, 2 witnesses, and complainant. Resident's transportation information, MAR, correspondence with doctor, medication list, care notes, diabetic diet, blood sugar log, and hospital discharge documents were obtained and reviewed.

Facility staff did not seek medical attention in a timely manner
Interview with complainant revealed that there was no specific incident where facility did not seek medical attention in a timely manner. Care notes revealed that 911 was called when R1 felt weak. (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: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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-20211027131428
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: 03/07/2023
NARRATIVE
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Facility staff are not arranging transportation for resident's medical appointment.
Interview with staff revealed that front desk was arranging transportation for R1. Transportation information indicated that facility was arranging transportation for R1 three days a week. Care notes indicated an incident where the car did not show up, but facility called another transportation service for R1 at a later time.

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: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5