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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:49:47 PM

Document Has Been Signed on 12/06/2024 05:49 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: 95DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Kristinia Morgan/Wellness Coordinator
and Bessy John/Care Coordinator 		TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At 12:30 pm on this day, December 6, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced in response to the Unusual Incident Report (UIR) received by the Department from the facility on December 5, 2024. LPA met with Wellness Coordinator (WC) Kristinia Morgan and Care Coordinator (CC) Bessy John and informed the reason for visit.

UIR indicated that on December 1, 2024, resident (R1) was out with R1's family when R1 was complained of pain in the left wrist. The family took R1 to the hospital where it was discovered that R1's wrist is broken.The UIR is missing last page (page 2) which LPA obtained from CC on this same day.

LPA reviewed R1's records and obtained copies of the following documents: Face Sheet; LIC602A Physician's Report; facility notes; hospital's After Visit Summary. LPA conducted interviews.

No deficiency cited on this day. WC has to leave the facility and gave permission to have CC sign and receive this report.

Exit interview conducted and copy of this report provided.
Bennett FongTELEPHONE: (510) 622-2621
Alicia DelmundoTELEPHONE: (510) 286-4201
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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