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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/04/2025
Date Signed: 04/04/2025 07:09:55 PM

Substantiated


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
10/08/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211008153646
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: 91DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Duncan Agyemang and
Ernesto 'Ernie' Buendia, Staff 		TIME COMPLETED:
07:10 PM
ALLEGATION(S):
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Staff did not clean resident's (R1) room.
INVESTIGATION FINDINGS:
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On this day, 4/04/25, at 12:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with staff, Duncan Agyemang and Ernesto Buendia. LPA called and spoke over the phone with Executive Director (ED) Dolly Rizvi, and informed the reason for visit.

During the course of investigation, LPA obtained copies of of the following: November 2020, December 2020 and current resident rosters; November 2020, December 2020 and current staff schedules.

Resident's (R1) family member (FM) stated that when R1 passed away in 2020, she was able to go to the facility on 12/26/2020 and collect R1's belongings. FM observed soiled clothes on the floor, soiled containers in the room and reddish liquid on the side of the bed, and that R1's room appeared not been cleaned for quite a while. Picture of the room was provided by FM.
....continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
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 6
Control Number 15-AS-20211008153646
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: 04/04/2025
NARRATIVE
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Page 2

LPA conducted inspection on 10/14/21 and interviewed staff on 12/06/24 and 4/04/25. All three housekeepers interviewed stated that during peak of Covid-19 on 2020 and 2021, there were only about 3, 4, 5 housekeepers. Two out of this 3 housekeepers stated they were not able to clean all the residents' rooms. One of these 2 housekeepers stated that this housekeeper was also assigned to do the laundry. Therefore, the allegation is substantiated. A finding that a complaint is substantiated means that the allegation is valid because the preponderance of evidence standard is met.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED over the phone. ED authorized Ernesto Buendia to sign and receive this report.

Exit interview conducted. Appeal Right, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/08/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211008153646

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: 91DATE:
04/04/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Duncan Agyemang and
Ernesto 'Ernie' Buendia, Staff 		TIME COMPLETED:
07:10 PM
ALLEGATION(S):
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-Resident (R1) was severely dehydrated.
-Staff did not notify responsible party of resident's (R1) change in health condition.
-Facility did not ensure the COVID-19 positive residents were isolated.
-Resident was missing teeth from dentures.
-Resident missing personal property.
INVESTIGATION FINDINGS:
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On this day, 4/04/25, at 12:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint. LPA met with staff, Duncan Agyemang and Ernesto Buendia. LPA called and spoke over the phone with Executive Director (ED) Dolly Rizvi, and informed the reason for visit.

During the course of investigation, LPA obtained copies of of the following: November 2020, December 2020 and current resident rosters; November 2020, December 2020 and current staff schedules; list of caregivers from agencies who worked in the facility. LPA also obtained copies of resident's following documents: Admission Agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Reports; Pre-placement Appraisal; facility notes and/or care notes/log; LIC621 Resident Personal Property And Valuables.

....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20211008153646
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: 04/04/2025
NARRATIVE
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Page 2

Allegation: Resident (R1) was severely dehydrated. - UNSUBSTANTIATED
R1's family member (FM) stated that on 11/04/20, the facility called and told FM that R1 needed to go to the hospital due to the resident not eating for 2 weeks. R1's doctor told FM that R1 was severely dehydrated. The 2 caregivers interviewed stated they give water to residents. One of these caregivers stated giving water to residents 4 to 5 times during their shift. LPA reviewed the documents obtained from the facility and the Plan of Care showed R1 came back from the hospital after being treated for UTI. There was no hospital discharge document or other document indicating R1 was dehydrated. LPA tried to obtain records from FM but unsuccessful.

Allegation: Staff did not notify responsible party of resident's (R1) change in health condition. - UNSUBSTANTIATED
FM stated that the facility did not inform FM that R1 was not eating and positive of COVID-19. R1's doctor told FM on 11/04/20 that R1 was positive of COVID-19.

LPA interviewed 4 staff (2 caregivers and 2 care coordinators) who all stated that when there's a change in resident's health condition, med-tech and facility nurse are informed who in-turn assess the resident. The med-tech or the facility nurse notifies the resident's family member. LPA also reviewed the copy of line list showing the names of residents who were tested positive of COVD-19 from 10/23/20 to 11/20/20 submitted by the facility to the Department of Public Health and provided to Community Care Licensing. R1 was not included on the list.

Allegation: Facility did not ensure the COVID-19 positive residents were isolated.
Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated that residents who tested positive of COVID-19 were isolated. Two of these staff stated that residents in Memory Care, because of dementia, came out of their rooms to the common area. One of these staff also stated that resident who's not positive of COVID-19 comes out to the common area.

....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20211008153646
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: 04/04/2025
NARRATIVE
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Allegation: Resident (R1) was missing teeth from dentures. - UNSUBSTANTIATED
Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard or observed any resident missing teeth from dentures. Two of these staff stated that residents dentures may gone were missing but were found in the residents clothing. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint.

Allegation: Resident (R1) missing personal property. UNSUBSTANTIATED
FM stated that R1's prescription glasses were missing. Six staff (2 caregivers, 2 housekeepers and 2 care coordinators) were interviewed who all stated they never heard any resident missing eyeglasses. One out of 2 residents interviewed stated not losing anything. The other resident stated not losing eyeglasses. LPA was not able to interview R1 as R1 had passed away prior to the Department receiving the complaint. R1's LIC621 Resident Personal Property And Valuables was reviewed which showed eyeglasses not listed.

Based on records review and interviews, the 5 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there's not a preponderance of evidence to prove that violations occurred.

No deficiency cited. The ED authorized Ernesto Buendia to sign and receive this report.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20211008153646
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director stated she'll in-service the staff. Proof to be submitted by 4/18/25.
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-This requirement is not met as evidenced by:

-Based on interviews, the licensee did not comply with the section above when the resident's room was not cleaned which posed personal rights risk to person 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6