015601083-4-24-2025-15-AS-HHUL-DHPUSX-20250616155101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 04/24/2025
Date Signed: 04/24/2025 01:48:37 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
07/20/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220720121412

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: 94	DATE:	04/24/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Dolly Rizvi/Executive Director		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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-Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit.

-Staff did not ensure that resident's (R1) bed was in working condition.

-Staff did not ensure that resident (R1) was adequately fed.

INVESTIGATION FINDINGS:

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On this day, April 24, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Executive Director (ED) Dolly Rizvi and informed the reason for visit.

During the course of investigation, LPA obtained copies of resident roster and staff schedule, reviewed resident's file, and conducted interviews. LPA obtained copies of resident's following documents: Face Sheet; LIC602A Physician's Report; LIC625 Appraisal/Needs and Services Pan; Hospital After Visit Summary. LPA also obtained copies of staff's LIC501 Personnel Record. The following were interviewed: reporting party (R1) on 7/21/22; staff (S1) and ED on 7/27/22; resident (R1) on 7/27/22; staff (S2 and S4) on 4/23/25

....continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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 4

Control Number 15-AS-20220720121412

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: 04/24/2025

NARRATIVE

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Page 2

Allegation: Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit.
The reporting party (RP) stated that the facility administrator (ED) refused to accept R1 back to the facility due to a bed issue. The RP stated that R1’s semi electric bed which was brought to the facility from R1’s home was broken and unless R1 is provided with a replacement bed, either a hospital bed or another semi electric bed, ED won’t admit R1 back, and that ED said R1 has not eaten in 24 hours and has become agitated because of the bed being broken.

ED denied the allegation that she refused to admit R1 back. ED stated the staff reported to her on 7/17/22 that the remote control of R1’s bed was broken and that R1’s daughters (FM1 and FM2) came to the facility on 7/18/22 and R1 was agitated because of the bed being broken and would not eat. R1 can feed self but would not want the staff put pillow to elevate/raise her head and was refusing to eat that day. ED also stated that she told the hospital several times to arrange the rental bed which will take only one hour, and that they can send the bill to the facility and the facility will get paid by the responsible party. ED further stated she told FM1 and FM2 they can rent a hospital bed temporarily, but the daughters were saying the insurance would not cover 100% of the cost. FM1 and FM2 told them to call 9-1-1 so R1 was sent out. R1 may also have UTI because R1 was very agitated that day. R1 was discharged back to the facility on 7/19/22.

R1 stated not remembering what happened to her bed. LPA observed R1’s bed was working on 7/27/22. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call.

S1 and S4 confirmed ED’s statement that the remote control of R1’s bed was broken and that R1 was agitated and refusing to eat. S1 stated R1’s bed was broken on and off and the issue reported to R1’s daughters. S1 also stated that R1 was sent out on 7/18/22 and discharged back on 7/19/22. Hospital After Visit Summary showed R1 was admitted on 7/18/22 for feeding and behavior problems and discharged on 7/19/22.

Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated.

....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20220720121412

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: 04/24/2025

NARRATIVE

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Page 3

Allegation: Staff did not ensure that resident's (R1) bed was in working condition.
S1 stated R1's bed has been on and off broken and R1’s daughters were informed and aware. Prior to the last time the bed was broken on 7/17/22, the daughter sent a motor to the facility and the motor of the bed was replaced. The bed was not a hospital bed, but part of the bed can be raised with a remote control. S4 confirmed that the remote control of R1’s bed was broken.

During interview on 7/27/22, R1 was not able to provide information about her bed but stated she’s happy. LPA observed R1’s bed was working that day. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call.

Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated.

Allegation: Staff did not ensure that resident (R1) was adequately fed.
S2 stated she fed residents during her shift and if residents refused to eat, she reported to her supervisor and facility nurse who gave her instructions what to do and she followed the instructions. S2 further stated they cannot force feed the residents, and that residents have right to refuse, but she came back and offer food 2 or 3x. She documented if resident still refused.

S4 stated the caregivers were feeding R1. S4 also stated that R1 knew that R1 has medications that needed to be taken with food. S4 further stated that she does not remember any incident where caregivers refused and/or didn't feed R1.

R1 stated she likes to eat dinner at 5:00 p.m. and dinner is already prepared at that time but was not able to provide information if caregivers refused to give her food.

....continued on 9099C (page 4)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20220720121412

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: 04/24/2025

NARRATIVE

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Page 4

Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated.

A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

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