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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:11:42 PM

Document Has Been Signed on 11/18/2024 12:11 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/
DIRECTOR:
DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 99TOTAL ENROLLED CHILDREN: 0CENSUS: 92DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Dolly Rizvi, AdminostratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 11/18/2024 at 9:15 AM, Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Dolly Rizvi, and explained the purpose of the visit. The facility’s fire clearance was approved for ninety nine (99) non-ambulatory residents, of which nine (9) may be bedridden and approved for eighteen (18) hospice.

LPA toured the facility with Wellness Coordinator Kristinia Morgan, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in visitor bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher all around the facility was last serviced on 10/15/2024.

At 10:02 am LPA reviewed 9 residents records. At 10:45 am, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Harpreet HumpalTELEPHONE: (510) 285-3928
Jill Clancy-CzulegerTELEPHONE: 510-286-4201
DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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