015601083-5-1-2026-15-AS-BFOG-DUQ2US-20260603174248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 05/01/2026
Date Signed: 05/01/2026 02:06:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/28/2026 and conducted by Evaluator Yasamin Brown

COMPLAINT CONTROL NUMBER: 15-AS-20260428120943

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: 99	DATE:	05/01/2026
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Bessy John, Care Coordinator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff did not prevent inappropriate interaction between two residents.

INVESTIGATION FINDINGS:

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On 5/1/2026 at 9:15 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegation above. LPA met with Bessy John, Care Coordinator and informed the reason for visit.

During investigation, LPA obtained the following documents for Resident (R1 and R2): Face Sheet, Care Plan, Appraisal Needs and Services Plan and LIC602(Phsyicians Report). LPA also obtained a copy of the incident report dated 4/10/2026. LPA conducted interviews with Staff (S1, S2 and S3) and residents (R1, R2, R3 and R4).

Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260428120943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER	FACILITY NUMBER: 015601083
	VISIT DATE: 05/01/2026

NARRATIVE

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Continued from LIC9099.

Allegation: Staff did not prevent inappropriate interaction between two residents.
Finding: Unsubstantiated

Interview with RP revealed that R1 stated that R2 had touched R1 on the shoulder and hand. Interview with staff revealed that this incident between R1 and R2 happened on 4/7/2026. S2 stated that they witnessed R2 walk past R1 in the common area and touched R1 on their shoulder and said "hello." S2 stated that they immediately redirected R2 away from R1 and took R2 outside. S1 stated that staff checked on R1 and made sure R1 was okay. Interview with R1 revealed that R2 touched their shoulder and hand and said "hello." R1 stated that S2 intervened immediately and separated R2 from R1. R1 stated that they feel safe living at the facility. R1 stated that R2 has not touched them again. LPA reviewed R1 and R2's appraisal needs and services plan and it indicated that R1 and R2 do not need a 1:1 staff person assigned to them. LPA observed that the facility contacted the resident responsible parties and implemented preventative measures.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies are being cited on this date. Exit interview conducted with Bessy John. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026

LIC9099 (FAS) - (06/04)

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