015601083-9-15-2026-15-AS-GLUK-DXZTAZ-20260917143423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 09/15/2026
Date Signed: 09/15/2026 02:15:48 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
01/26/2026 and conducted by Evaluator Yasamin Brown

COMPLAINT CONTROL NUMBER: 15-AS-20260126112118

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: 98	DATE:	09/15/2026
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Dolly Rizvi, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not address resident's change in condition in a timely manner.

INVESTIGATION FINDINGS:

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On 9/15/2026 at 2:00 pm, Licensing Program Analyst (LPA), Y. Brown arrived unannounced to deliver complaint findings for the allegation 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 three (3) staff, two (2) witnesses, and three (3) residents. The Department also collected records, including medical records from Kaiser Permanente and Royal Ambulance EMS report. Resident records including R1, R2, R3, and R4’s Progress notes, incident Reports (December 2025 and January 2026), LIC602 (Medical Assessment), identification and emergency contact, Care Plan, Physicians fax report, and Appraisal Needs and Services Plan were also reviewed and copies obtained. R1’s face sheet, internal incident report, unusual incident/injury report, after visit summary discharge document, and progress notes were also reviewed and copies obtained.

Continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026

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-20260126112118

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: 09/15/2026

NARRATIVE

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Continued from LIC9099.

Allegation: Staff did not address resident's change in condition in a timely manner.

Finding: Unsubstantiated

During record review, the department reviewed the facilities internal incident report and unusual incident/injury report and observed that on 1/21/2026, R1 began vomiting and feeling weak around 4pm. Interviews with staff stated that the nurse was called to assess R1. S2 stated that they called 911 and the EMT’S arrived shortly after. Interviews with staff revealed that R1 was not sick or showing signs of a change of condition prior to the incident on 1/21/2026. LPA reviewed R1’s progress notes dated 1/19/2026 and 1/20/2026 and observed that R1 was not experiencing a change of condition. LPA reviewed R1’s progress notes dated 1/21/2026 and observed that it states that R1 was eating snacks and then started throwing up. Staff denied not assisting R1 in a timely manner. W2 stated that the facility makes them aware of R1’s change of conditions. LPA reviewed R1’s medical discharge document from Kaiser Permanente dated 1/23/2026 stated, “Pt normally can follow some directions, and verbalize some needs per staff. Today pt is not tracking, with no movement and she is now contracted. Staff says pt is not normally contracted.”

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

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026

LIC9099 (FAS) - (06/04)

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