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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:13:39 PM


Document Has Been Signed on 09/27/2024 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
015601083
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:99CENSUS: 89DATE:
09/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kristinia Morgan/Wellness CoordinatorTIME COMPLETED:
03:15 PM
NARRATIVE
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While conducting an investigation of a complaint (Control # 15-AS-20211026093939), resident (R1) showed to Licensing Program Analyst (LPA) Delmundo a wound on R1’s right elbow while LPA was interviewing R1. The wound was about 2 inches x 1 1/2 inches with fresh blood, skin scraped and part of flesh exposed. LPA interviewed the staff (S6) who was assigned to R1 that day. S6 stated she observed R1's wound on the right elbow that day and that the blood was fresh. She attended to other residents and forgot to put bandage on R1's wound nor report to the facility nurse (LVN). S6 further stated does not know what happened and that it could be that R1 hit the bed rails. LPA called LVN who confirmed it was not reported to her. LVN attended to R1 after LPA spoke with her.

On this day, September 27, 2024, LPA conducted a case management resulting from the above. LPA met with Wellness Coordinator (WC), and informed the reason for visit. LPA also spoke over the phone with Executive Director (ED) Dolly Rizvi. The ED gave permission to WC to sign and receive this report.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED over the phone in the presence of WC.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/27/2024 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General:
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
-This requirement is not met as evidenced by:
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Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 9/28/24.
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-Based on observation and interviews, the licensee did not comply with the section above when staff did not attend to R1 nor call the facility nurse when R1 sustained injury which posed an immediate health, safety and/or personal rights risks to person 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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