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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 07/08/2026
Date Signed: 07/08/2026 04:17:52 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
07/02/2026 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20260702105209
FACILITY NAME:MARYMOUNT VILLA RETIREMENT CENTERFACILITY NUMBER:
015601083
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:99CENSUS: 97DATE:
07/08/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dolly Rizvi, Executive Director TIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff do not provide activities to residents in care
Staff are placing restrictions on visitations for residents
Staff did not received a completed medical assessment before acceptance of resident
Staff will not allow resident to leave the facility unassisted
INVESTIGATION FINDINGS:
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On 7/8/2026 at 10:00 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Dolly Rizvi, Executive Director and explained the purpose of the visit.

During the investigation, LPA interviewed staff (S1, S2, S3, and S4) and Residents (R1,R2, R3 and R4). LPA toured the facility and obtained and reviewed the facilities LIC500 (Personnel Record) and resident roster. LPA reviewed and obtainted R1's LIC602 (Physicians Reports), Face Sheet, Care Plan/ LIC625 (Appraisal Needs and Services Plan), and Physican Fax Letter.

Allegation: Staff do not provide activities to residents in care
Finding: Unsubstantiated

Continued on LIC9099-C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20260702105209
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: 07/08/2026
NARRATIVE
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Allegation: Staff will not allow resident to leave the facility unassisted
Finding: Unsubstantiated

During record review, LPA observed that R1's LIC602 dated 5/8/2025 and 2/23/2026 stated that R1 "can not leave the facility unassisted." Interviews with staff revealed that they followed these guidelines and did not allow R1 to leave the facility unassisted. LPA observed that R1's most recent and updated LIC602 dated 4/17/2026, stated that R1 "can leave the facility unassisted." Interviews with staff revealed that since they received the new medical assessment they do not deny R1 from leaving the facility unassisted. Interview with R1 revealed that in the past staff did not allow them to leave unassisted but with the new updated medical assessment they are able to leave unassisted. LPA reviewed the Resident sign out sheet and observed that R1 has signed out multiple times and has been leaving the facility unassisted since the new medical assessment dated 4/17/2026.

Based on interviews, record review and observations conducted, the above allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit Interview conducted with Dolly and copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20260702105209
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: 07/08/2026
NARRATIVE
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Continued from LIC9099.

During facility tour, LPA observed that the facility has a white board in the dining hall/common area that details the activities for the day. LPA observed residents attending the scenic drive that was scheduled for 10:00 am and the movie time that was scheduled at 1:30 pm. During record review, LPA reviewed the activities calendar. Interviews with residents revealed that the facility offers a variety of activities. R1 stated that the facility offers bingo and outings. R3 stated that the facility has a lot of activities such as walking, bingo, and movies. R4 stated that the facility offers different activities everyday. Interview with S2 revealed that the facility offers a variety of activities and there is a resident council meeting (every 3 months) where residents can bring up suggestions for new activities.



Allegation: Staff are placing restrictions on visitations for residents
Finding: Unsubstantiated

During investigation, LPA reviewed the house rules that states that visitation hours are from 8:00 am-8:00 pm. Interview with S1 revealed that the facility previously had the COVID visitation policy posted but the restrictions on visitors are not being enforced. LPA observed that the COVID policy was not posted during visit. Interview with S2, S3, and S4 revealed that the facility does not enforce the previous COVID policy and they enforce the house rules visitation policy. Interviews with staff stated that if visitors want to visit before 8:00 am or after 8:00 pm, they just have to let the front desk know and the staff will accommodate them. Interviews with staff revealed that they deny placing restrictions on visitations for residents. Interview with residents revealed that their visitors are not restricted and are allowed to visit them at any time.

Allegation: Staff did not received a completed medical assessment before acceptance of resident
Finding: Unsubstantiated

During record review, LPA observed that R1 was admitted to the facility on 5/13/2025. LPA reviewed R1's LIC602 and observed that it was dated on 5/8/2025 before R1 was admitted. Interview with S1 revealed that R1 did receive a medical assessment before being admitted. Interview with R1 revealed that they obtained a medical assessment before moving in.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3