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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:04:59 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
07/11/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250711145942
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: 93DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dolly Rizvi, Executive Director/AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff blocks an exit doors presenting a hazard to residents
INVESTIGATION FINDINGS:
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On 07/17/25 at 11:30AM, Licensing Program Analysts (LPA) D Panlilio and Y Brown conducted an unannounced complaint visit, met with Executive Director/Administrator (ED/ADM). LPAs explained the purpose of the visit with ADM. LPAs conducted interviews & record reviews and delivered investigation findings to ADM.

Allegation: Facility staff block exit doors presenting a hazard to residents
Investigation Finding: Substantiated
During investigation, LPAs interviewed staff (ED/ADM) and reporting party (RP) who confirmed that on 07/07/25 and 07/11/25 the emergency exit doors on the 3rd, 4th and 5th floors were still blocked with a bench and a potted plant to prevent dementia residents from seeking an exit. ED/ADM stated that they conducted a fire safety in-service training with all staff on 07/11/25, 07/14/25 and 07/15/25.

Continued on next page, LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 3
Control Number 15-AS-20250711145942
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: 07/17/2025
NARRATIVE
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Based on LPA’s interviews and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) that facility staff block emergency exit doors presenting a hazard to residents was found to be substantiated. This is a repeat violation of Title 22 Section 87203 Fire Safety which was issued on 02/21/25. An immediate civil penalty of $500 is being assessed due to fire clearance violation.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250711145942
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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2025
Section Cited
CCR
87203
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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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Deficiency cleared during visit on 07/17/25.

ED/ADM completed n-service staff re-trainings on fire safety in compliance with Section 87203 on 071/1/25, 07/14/25 and 07/15/25.
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This requirement was not met as evidenced by staff failing to keep emergency exit doors unobstructed which posed an immediate health and safety risk to residents in care.
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An immediate civil penalty of $500 is being assessed due to fire clearance violation.
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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: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3