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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:56:59 PM

Document Has Been Signed on 11/19/2024 02:56 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: DATE:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Dolly Rizvi,AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 11/19/24 at 2:35 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver an amended report from the visit that occurred on 10/01/24. LPA met with Administrator, Dolly Rizvi and explained the purpose of the visit.

Amended report delivered.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.


Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Gregory ClarkTELEPHONE: 510-285-3927
DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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