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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601083
Report Date: 05/12/2021
Date Signed: 05/12/2021 04:54:23 PM

Document Has Been Signed on 05/12/2021 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
015601083
ADMINISTRATOR:DOLLY RIZVIFACILITY TYPE:
740
ADDRESS:345 DAVIS STREETTELEPHONE:
(510) 895-5007
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 99CENSUS: 49DATE:
05/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Dolly Rizvi, AdministratorTIME COMPLETED:
05:05 PM
NARRATIVE
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On 5/12/2021 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to conduct a case management inspection in regards to incident report received on 5/10/2021. LPAs met with Administrator, Dolly Rizvi.

Incident report dated 5/10/2021 revealed that R1 AWOL and facility notified law enforcement and R1's responsible party. R1 was found by police a couple hours later and was escorted back to the facility.

Interview with S1 revealed that R1 left the facility during morning shift change. S1 stated that facility staff looked for residents near BART and local shops, but unable to find R1. Facility staff called police and police was able to find R1 after a couple hours. S1 stated that R1 was given a different medication dosage when family member was caring for R1. S1 has changed noc/morning shift change procedures after incident to prevent future AWOLs. R1 has a new doctor's order for medications after consulting with R1's family.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.

Exit interview conducted with Dolly Rizvi. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2021 04:54 PM - It Cannot Be Edited


Created By: Grace Luk On 05/12/2021 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2021
Section Cited
CCR
87705(c)(4)

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Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical, ...safety...needs... This requirement is not met as evidence by:
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Administrator has agreed to provide an updated care plan for R1 and have a new AWOL procedure. Administrator will submit R1's care plan and AWOL procedure to CCLD by POC date.
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Based on interview, licensee did not comply with the section cited above due to resident AWOL which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2021


LIC809 (FAS) - (06/04)
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