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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 08/01/2025
Date Signed: 08/01/2025 02:39:18 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
07/28/2025 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20250728102149
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: 96DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Care Coordinator, Bessy JohnTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in residents eloping.
INVESTIGATION FINDINGS:
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On 08/1/25 at 11:00AM, Licensing Program Analysts (LPA) K. Nguyen and Y Brown conducted an unannounced complaint visit, met with Care Coordinator, Bessy John. LPAs spoke with Executive Director/Administrator (ED/ADM) via phone and received permission for Bessy to sign the report. LPAs explained the purpose of the visit with ADM. LPAs conducted interviews & record reviews and delivered investigation findings to Care Coordinator.

Allegation: Staff did not provide adequate supervision resulting in residents eloping.
Investigation Finding: Substantiated
During investigation, LPAs interviewed S1,S2, S3,S4,and S5 and reporting party (RP). LPAs reviewed and requested staff and resident roster, and the following documents from resident's (R1 & R2) file: Physician's Reports, Appraisal Needs and Services Plan, and Police Report.

Continued on next page, LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
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-20250728102149
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: 08/01/2025
NARRATIVE
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...continued from LIC9099.

Staff did not provide adequate supervision resulting in residents eloping.

LPAs interviewed S3 and S3 stated that R1 and R2 were fighting with each other before S3 took the residents outside. S3 stated that they left R1 and R2 outside unattended while they went inside the facility. S3 stated that they went inside to tell the front desk that they were leaving the residents outside. S3 stated that "they forgot the residents outside" and S3 stated that they thought the residents "went inside themselves." S3 stated that "R1 and R2 like to be outside by themselves." S3 stated that "the staff got busy and didn't know where the residents went." LPAs reviewed R1 and R2's Physician's Report (LIC602) and it revealed that R1 and R2 are unable to leave the facility unassisted.


Based on information obtained, the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted, appeal rights and a copy of this report provided to Bessy John.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20250728102149
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: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2025
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...

This requirement was not met as evidence by:
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Administrator will create a plan to implement a system that helps elopments reduce. Proof of correction will be sent to CCLD by POC date.
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Based on interview and record review, the licensee did not comply with the section cited above in having R1 and R2 left unattended which resulted in residents eloping in which poses an immediate health and safety risk to persons 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: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3