015601083-8-17-2026-15-AS-GLUK-DXJSLF-20260902135817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 08/17/2026
Date Signed: 08/17/2026 05:28:58 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
11/06/2025 and conducted by Evaluator Yasamin Brown

COMPLAINT CONTROL NUMBER: 15-AS-20251106165249

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: 96	DATE:	08/17/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Dolly Rizvi, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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A resident sustained unexplained injuries while in care.
Staff did not notify resident's responsible party of an incident.

INVESTIGATION FINDINGS:

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On 8/17/2026 at 9:30 am, Licensing Program Analyst (LPA), Y. Brown arrived unannounced to deliver complaint findings for the allegations above. LPA met with Dolly Rizvi, Executive DIrector and explained the purpose of the visit.

The Department’s investigation included but was not limited to interviews with 3 residents, 7 staff, 4 witnesses and reviewed records. The Department also collected records, including medical records from Alameda Health Systems and a copy of the San Leandro Police Department (SLPD). R1’s LIC602 (Physician’s Report), Face sheet, Prescribed Medication Dispensement Log, Caregiver Endorsement Notes, Incident reports and employee roster were also reviewed and copies obtained. LPA obtained and reviewed R1's face sheet, progress notes, and incident report. LPA also obtained and reviewed email documentation.

Continued to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

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-20251106165249

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: 08/17/2026

NARRATIVE

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Continued from LIC9099.

Allegation: A resident sustained unexplained injuries while in care.

Finding: Unsubstantiated

The Department conducted staff interviews and S1, S2, S3, S4 and S5 corroborated with W3’s statement that R1 had some scattered scabs and areas of skin breakdown and R1 has a history of skin breakdown and struggled with behaviors of aggression and would hit their body on surrounding furniture when they got upset. Staff stated that R1 would become combative and aggressive, but staff would try to calm R1 and redirect, preventing R1 from self-harm. Staff denied hurting or causing any injuries to R1. Interviews with R2, R3, and R4 revealed that they have never witnessed or experienced any injuries from staff. Based on interviews and record review, there is a lack of evidence to conclude that R1 sustained unexplained injuries while in care. Based on the investigation, S1 stated that R1 was taken to the San Leandro Hospital on 11/6/2025, due to increased agitation and aggressive behaviors toward staff. Review of R1’s discharged record of 11/18/2025 received from Alameda Health Systems, indicated that R1’s observed bruises, “were scattered shin scabs and skin breakdown on Bilateral Upper Extremities (BUE) likely from fragile, atrophic skin from age.”

Allegation: Staff did not notify resident's responsible party of an incident.

Finding: Unsubstantiated

During record review, LPA observed that R1 had a previous conservator but obtained a new conservator on 11/3/2025. LPA reviewed email correspondence on 11/4/2025 between the facility and the current conservator being notified of R1's pre existing conditions and R1 being sent to the hospital on 11/6/2025.

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

Exit interview conducted with Dolly and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

LIC9099 (FAS) - (06/04)

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