015601083-4-19-2023-15-AS-KHOS-CTLQXU-20230710123406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/19/2023
Date Signed: 04/19/2023 07:12:51 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
04/13/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230413152734

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: 71	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Dolly Rizvi/Executive Director		TIME COMPLETED:	07:20 PM

ALLEGATION(S):

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-Unexplained rapid weight loss of resident.

-Staff not responding to resident's callls for help

-Failure to call 911.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Executive Director (ED) Dolly Rizvi, and informed the reason for vist.

LPA obtained copies of resident roster and staff schedule. LPA reviewed residents' records and obtained copies of following documents: LIC601 Identitification and Emergency Contact Information/Face Sheet; LIC602A Physician's Report; Appraisal/Needs and Services Plan; weight records. LPA interviewed 4 staff, the ED. 6 residents and resident's family member (FM).

,,,,continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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-20230413152734

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: 04/19/2023

NARRATIVE

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Allegation: Unexplained rapid weight loss of resident (R1)
LPA interviewed the ED who stated residents are weigh once a month and weights are recorded. The ED indicated that residents sometimes refuse to be weigh. This ED's statement was confirmed by 4 staff interviewed. Review of records showed residents were weighed once a month. R1 refused to be weigh on one of the month on the record. Record also showed no drastic change on R1's weight.

Allegation: Staff not responding to resident's calls for help
It was alleged that when R1 calls for help, R1 is ignored by staff. All staff interviewed indicated that if resident calls for help, they come and check the resident within 5 minutes or less. If resident need to be assessed, med-tech or the facility nurse is called. Four out of 6 residents interviewed stated caregivers attend to them whenever they call for help. One of the resident indicated he uses call button to call for help and if no one shows up right away, he uses walkie talkie. LPA was unable to obtain information from R1.

Alegation: Failure to call 911
It was alleged that when resident asked staff to call 911, staff refused. LPA interviewed 4 staff who all indicated they call 911 is when needed. All four staff indicated that R1 has behavior of wanting to call 911. R1's family member (FM) was interviewed who stated that when R1 was living in R1's home, R1 calls 911 every 2, 3 days which R1 does when R1 moved to the facility. FM further stated that the facility nurse keep a close contact and inform FM. Review of records showed R1 has dementia, somatic delusional disorder and anxiety.

Based on all information gather, the 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

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