015601083-9-27-2024-15-AS-BFOG-DA636V-20241017175859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:12:17 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
10/26/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211026093939

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: 89	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Kristinia Morgan/Wellness Coordinator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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-Resident (R1) sustained a fractured finger while in care.

-Facility staff hit resident (R1).

INVESTIGATION FINDINGS:

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On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings on the above allegations. LPA met with Wellness Coordinator (WC) Kristinia Morgan, 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.

During the course of investigation, LPA reviewed residents’ records and obtained copies of including but not limited to the following residents’ documents: LIC601 Identification and Emergency Information and Face Sheet; LIC602A Physician's Reports; Pre-placement Appraisal; Appraisal/Needs and Services Plan; Unusual Incident/Injury Reports; hospital discharge document and/or Hospital After Visit Summary.

On 11/02/21, 4/08/22 and 8/13/24, LPA interviewed residents (R1, R2, R3, R4, R5) and staff (S1, S2, S3, S4 and S5) and R1’s family member (FM).
.....continued on 9099C (page 2)

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20211026093939

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: 09/27/2024

NARRATIVE

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Allegation: Resident (R1) sustained fractured finger while in care.

On 11/02/21, LPA Delmundo interviewed S1, S2, S4, S6, and R1. S2 stated having observed R1 had purplish discoloration at one of the small fingers that on 10/24/21, and that R1 yelled out when it was touched. S2 then had R1 transferred to hospital for evaluation. All other staff interviewed was not able to provide information as to how the injury occurred. S6 stated having observed a fresh wound at R1’s right elbow but had no knowledge of how it happened. S2 and S7 were not aware of the subject incident. S1 reported being aware that the facility’s LVN observed that R1 had swelling on one of R1’s finger. S4 only stated having knowledge that R1 was transferred to hospital due to a swollen finger. R1 reported not remembering how the wound happened and did not state that there was any staff involvement.

On 8/13/24, LPA Delmundo interviewed FM, who reported being aware that R1 was sent to hospital for the finger injury; and that R1 can be combative and “out of control” and “could see” R1 causing self-injury due to the behaviors.

On 11/2/21, LPA Delmundo reviewed R1’s file and observed the Physician’s report indicating a diagnosis of Dementia with Behavioral Disturbance.

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

Allegation: Facility staff hit resident (R1).

During complaint intake, the reporting party (RP) stated that R1 informed the RP that R1 is beaten by facility staff. The RP further stated that RP had spoken to FM, who reported being aware that R1 needed transfer to the hospital for an injury. FM further stated that R1 is “manipulative,” “delusional,” and “paranoid”; and did not believe that staff had hurt R1, but that due to aggressive behavior R1 has hurt the staff; and that R1 showed no caution for self-safety. RP stated R1 was sent to hospital via ambulance and diagnosed with right finger fracture.

....continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20211026093939

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: 09/27/2024

NARRATIVE

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All 5 staff (S1-S5) interviewed denied hitting residents and stated not observing any staff hitting residents. S4 stated there was an incident when R1 twisted a spoon and scratched S4. S1 confirmed R1 was sent out on 10/2021. S2 stated R1 asked S2 to check R1’s finger and S2 observed discoloration on the left pinkie and R1 was transferred to hospital; however, R1 was discharged back to the facility without the After Visit Summary. Facility’s Internal Incident Report matched S2’s statement.

R1 was not able to provide information regarding the subject incident and indicated that staff are “good.” R3 and R4 declined to be interviewed. R2 and R5 stated having no knowledge of or having been aware of staff abusing any resident.

Review of R1’s records showed R1 has dementia, aggressive behavior, and behavior disturbance. LPA interviewed R1’s family member (FM) who confirmed RP and staff’s statements that R1 has agitation and behavior issues. FM stated R1 was combative and hurt herself.

Based on all information gathered, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations 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: 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

LIC9099 (FAS) - (06/04)

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