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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 08/27/2025
Date Signed: 08/27/2025 11:55:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/31/2025 and conducted by Evaluator Yasamin Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250731152150
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: 97DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Dolly RizviTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff will not allow accept resident at facility
INVESTIGATION FINDINGS:
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On 08/27/2025 at 10:30 AM, Licensing Program Analysts (LPAs), Y. Brown and C. Fowler arrived unannounced to deliver a complaint finding for the allegation above. LPAs met with Administrator Dolly Rizvi and explained the reason for the visit.
During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records.
Allegation: Staff will not allow accept resident at facility

During the investigation W1 was interviewed and stated R1 was admitted into Kaiser Medical Center San Leandro on July 30, 2025. W1 further stated when R1 was ready to be discharged that evening S1 stated facility will not accept R1 unless he had a private caregiver. W1 stated R1 was discharged on August 1, 2025, with a private caregiver that worked with R1 until August 4, 2025.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
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-20250731152150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083
VISIT DATE: 08/27/2025
NARRATIVE
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Continued from LIC9099.

During the interview with S1, S1 stated due to R1’s diagnosis R1 needed a private caregiver to keep him isolated and would not take him back into the facility without a private caregiver. S1 had spoken with Kaiser staff and R1’s responsible party. S1 stated R1’s responsible party refused to pay for a private caregiver. On August 1, 2025, R1 had a private caregiver provided by Kaiser and was transported back to the facility via ambulance. LPAs reviewed the facility’s infection control plan. On page 17 of the infection control plan it states “Hospital discharge and admission or re-admission to a facility should not be delayed or prevented due to the COVID-19 status of the patient.”


Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250731152150
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2025
Section Cited
CCR
87468(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities [...] shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs [...] and competency to meet their needs.
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Administrator agreed to conduct in-service training for all employees regarding the infection control plan and submit sign-in sheet to CCLD by POC date.
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This requirement is not met as evidenced by:
Based on interview, the licensee did not comply with the section cited above for not allowing R1 to return back to the facility due to the COVID-19 status of the patient which poses a potential safety risk to the 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3