015601083-4-6-2023-15-AS-YFLS-CSSVRZ-20230614164045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:35:33 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
04/28/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220428162007

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: 74	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Dolly Rizvi, Executive Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident sustained a head injury while in care
Staff did not seek medical attention for resident in a timely manner
Staff did not inform resident's authorized representative of injury in a timely manner

INVESTIGATION FINDINGS:

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On 4/6/23 starting at 11:50 AM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Executive Director, Dolly Rizvi and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents, reviewed records and interviewed staff. It was alleged resident sustained a head injury while in care and staff did not seek medical attention for resident in a timely manner. Based on record review of R1's discharge notes, R1 was diagnosed with traumatic injury of head with hematoma of scalp. Based on interview with S1, S1 stated S1 was assisting R1 with toileting on 4/25/22. While sitting on the toilet, R1 fell on her side and bumped the side of her forehead against the rails of the commode.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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-20220428162007

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: 04/06/2023

NARRATIVE

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LPA discovered during a review of R1's incident report that S1 applied ice pack on R1 and resident refused to go to the hospital. R1 was monitored closely by care staff and once staff observed swelling, S2 contacted non-emergency transportation. S2 contacted R1's responsible party and informed of wait time so S2 was instructed to call 9-1-1 by R1's responsible party instead.

It was alleged staff did not inform resident's authorized representative of injury in a timely manner. However, during record review of R1's incident report on 4/6/23, both R1's conservator and family member were both notified by S2 of the incident that occurred on 4/25/22. S3 stated S2 left a voicemail for R1's conservator then notified R1's family member.

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 and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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