015601083-5-15-2026-15-AS-BFOG-DUQ2YM-20260603174859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 05/15/2026
Date Signed: 05/15/2026 11:15:19 AM

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
12/23/2025 and conducted by Evaluator Yasamin Brown

COMPLAINT CONTROL NUMBER: 15-AS-20251223190548

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:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Bessy John, Care Coordinator		TIME COMPLETED:	11:30 PM

ALLEGATION(S):

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Staff interfered with resident visitation

INVESTIGATION FINDINGS:

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On 5/15/2026 at 9:30 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Bessy John, Care Coordinator and informed the reason for visit.

During the investigation, LPA interviewed 4 residents, 4 staff members, and W1, W2 and W3. LPA obtained and reviewed the following resident documents: Care Plan, Emergency Information and Contact, Admission Agreement, LIC602 (Physician's report), and Appraisal Needs and Services Plan.

Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

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-20251223190548

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: 05/15/2026

NARRATIVE

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Continued from LIC9099.

Allegation: Staff interfered with resident visitation
Finding: Unsubstantiated

During investigation, LPA conducted interviews with W1, W2, W3, residents, staff and reviewed R1’s documents. Review of R1’s admission agreement dated 11/13/2023 showed that the visitation hours are 7 days a week from 9AM to 7PM. S1 stated that W1 has come to the facility to see R1 but not during visitation hours. S2 stated that W1 has come to the facility at 6am or even at 8pm (not sure on exact dates). W1 stated that they have come to the facility to visit R1 but not during visitation hours due to their work schedule. W1 stated that the facility has accommodated W1 with seeing R1 not within the visitation hours. S1, S2, S3, S4, and W1 stated that R1 has a roommate. S2 stated that for all residents, if a resident has visitors but they have a roommate, the visitors are still allowed to visit them in their room, but the visitors do have a limit on how long they can be in the room out of respect for their roommate.

Based upon the interviews and record review conducted during the investigation, the above allegation is 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 violation occurred.

Exit interview conducted with Bessy and a copy of report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

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