015601083-4-6-2023-15-AS-YFLS-CWXRQP-20231025131351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:34:28 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
02/27/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230227161634

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:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Dolly Rizvi, Executive Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility did not provide adequate care resulting in resident sustaining unexplained pressure sores while in care

Facility did not observe resident's changes in condition resulting in infections.

Facility did not safeguard resident's dentures

INVESTIGATION FINDINGS:

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On 4/6/23 starting at 11:50 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conuct complaint investigation for the above allegations. LPA met with Executive Director, Dolly Rizvi and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents, reviewed records and interviewed staff. It was alleged facility did not provide adequate care resulting in resident sustaining unexplained pressure sores while in care. Based on information obtained, R1 sustained pressure sores on lower extremities. W1 stated when R1 was admitted to the new facility, an open sore was observed in R1's private area. However, based on record review, LPA observed a fax on 6/27/22 to R1's primary care physician of facility requesting a doctor's order of ATB ointment and calmesoptine to be applied to R1's thigh and groin area.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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-20230227161634

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: 04/06/2023

NARRATIVE

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It was alleged facility did not observe resident's changes in condition resulting in infections. Based on interview with 3 staff, body checks are conducted during showers and staff will inform med-tech or nurse on duty if staff observes any unusual marks on residents body. R1 had a history of cellulitis and during record review, LPA observed a history of communication with R1's podiatrist.

It was alleged facility did not safeguard resident's dentures. LPA reviewed R1's property and valuables, and LPA did not observe R1's denture listed on LIC 621. However, S1 stated that R1 tends to remove her denture because the fitting was tight and uncomfortable. S1 stated when R1's family member found the denture in R1's pocket, R1's family member removed it from facility. LPA was unable to prove or disprove allegation.

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

Exit interview conducted and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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