015601083-4-8-2022-15-AS-KHOS-CDLJ8A-20220418064909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:47:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/01/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200301160704

FACILITY NAME:	MARYMOUNT VILLA RETIREMENT CENTER		FACILITY NUMBER:	015601083
ADMINISTRATOR:	JASMINE SEABOURNE		FACILITY TYPE:	740
ADDRESS:	345 DAVIS STREET		TELEPHONE:	(510) 895-5007
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	99	CENSUS: 75	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Lydia Olson/Activities Coordinator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff do not ensure that resident (R1) is adequately fed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Activities Coordinator Lydia Olson and informed the purpose of visit. LPA called and spoke with Executive Director Dolly Rizvi who authorized Lydia Olson to sign and receive this report.

It was alleged that R1 ordered hot dog but the hot dog never arrived and R1 was served chicken which R1 hates. R1 was not served anything else that R1 could eat.

During the course of investigation, LPA obtained copies of resident rosters, staff schedule and menus. LPA reviewed resident records and conducted interviews.

....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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-20200301160704

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER	FACILITY NUMBER: 015601083
	VISIT DATE: 04/08/2022

NARRATIVE

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LPA interviewed staff (S1, S2, S3 and S4). S1 said R1 eats everything unless R1 is not in good mood. S1 stated R1 likes hot dog, hamburger and fries. S2 said R1 likes hot dog a lot and if R1 does not like the meal for the day, R1 is given hot dogs. All 4 staff indicated if residents do not like the meal for the day, they are given options which LPA confirmed with resident (R3). S5 stated that there's daily menu on paper and residents can also ask for substitute. S5 indicated that the chef orders food supplies every Thursday and items like egg sandwich, cheeseburgers, turkey or ham sandwich, and hot dogs are normally fully stocked. If item is not available, the front desk person is asked to change the menu day prior which LPA confirmed with the front desk person.

On November 2, 2021, LPA Delmundo tried to interview R1 and R1 declined. LPA tried to interview R2 and R4 but unsuccessful.

On April 1, 2022, LPA L. Holmes tried to interview R1 but was unable to obtain relevant information regarding menu and food R1 likes.

Residents (R5 and R6) stated if they don't like the menu for the day, they are given substitute. R7 and R8 have no complaint while R9 is not satisfied with the food.

Based on all the information gathered and LPAs unable to obtain information from R1, the allegation is closed as unsubstantiated. A finding is unsubstantiated means that 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.

Exit interview conducted and copy of this report provided to Lydia Olson.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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