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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 09/18/2024
Date Signed: 09/18/2024 12:29:41 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
07/07/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230707150358
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: 87DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dolly Rizvi, Excutive Director TIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Illegal eviction
Staff refused to accept resident back from hospital discharge
INVESTIGATION FINDINGS:
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On 9/18/2024 at 11:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to deliver the findings for the above allegations. LPA meet with Executive Director, Dollie Rizvi and explained the purpose of the visit.

The allegation refers to R1 received an eviction notice due to R1 conservator no longer want to be responsible for R1 medical, and financial. During the investigation, LPAs interviewed staff and attempted to interviewed resident, but resident was no longer reside at the facility. LPAs reviewed documents of the time frame that facility had issues an eviction noticed to R1. Base of documentations provided by S1.
R1 conservator emailed S1 on 5-17-2023 stated that R1 trust fund was no longer available, and R1 conservator is no longer responsible for R1. The fund that R1 have left is enough to pay for the month of June 2023. R1 was sent out to the hospital on July 4, 2023. Facility sent R1 a 30-day eviction noticed on June 1, 2023, and indicated the move out date by July 1, 2023, therefore the allegation is unsubstantiated.

Report continued page LIC 9099c…
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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 2
Control Number 15-AS-20230707150358
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: 09/18/2024
NARRATIVE
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During the investigation LPAs interviewed and reviewed documents between S1 and R1 social worker via email exchange. The documents stated S1 did not denial R1 back to the facility after R1 gets discharge, but due to R1 health concerned R1 was sent to a SNIFF after the hospital discharged R1, therefore this allegation is unsubstantiated.

Although the allegations may have happened or are valid, there are 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2