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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 09/24/2025
Date Signed: 09/24/2025 05:30:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
06/27/2025 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250627153453
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: DATE:
09/24/2025
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Dolly Rizvi, Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff did not make resident's records available to their designated representative upon written consent
INVESTIGATION FINDINGS:
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On 09/24/2025 at 4:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director (ED) Dolly Rizvi to deliver the findings of above allegation. LPA explained the purpose of the visit with ED.

During investigation, the LPA obtained the following documents from the facility – Residents Listing, Staff Roster, Resident (R) R1's Admissions Agreement, R1's Face Sheet, copy of email (dated 06/26/25), copy of R1's Durable Power of Attorney for Financial Management (dated 05/20/23), copy of California Advance Health Care Directive (dated 05/20/23), copy of R1's Assisted Living Waiver Informing Notice (dated 11/26/24), R1's Physician's Report, care notes, incident reports and Copy of Policy Procedures for Medical records.

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
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-20250627153453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083
VISIT DATE: 09/24/2025
NARRATIVE
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LIC9099-C (Page 2)

Allegation: Staff did not make resident's records available to their designated representative upon written consent
Finding: Substantiated

On 07/01/2025, Licensing Program Analyst (LPA) L. Alexander interviewed Witness (W1). W1 stated that on 06/04/2025, they submitted a request for R1’s file via fax. After allowing one week for acknowledgment, W1 followed up with the facility on 06/11/2025 by emailing the authorization and status request to Staff (S2) and leaving a voicemail message. W1 reported no response was received. W1 confirmed that R1 was a former resident of the facility.

On 07/02/2025, LPA interviewed Staff (S1). S1 confirmed a faxed request was received but stated they were unsure which document W1 was referring to due to the volume of faxes. S1 stated that per facility policy, once a resident leaves the facility, S2 is responsible for reviewing and releasing records.

LPA reviewed the following documents: Authorization to Handle Claim (05/29/2025), Authorization to Release Medical Documents (06/04/2025), Durable Power of Attorney for Financial Management (05/20/2023), Advance Health Care Directive (05/20/2023), Subpoena Request for Medical Records (06/04/2025), and the facility’s Policy for Release of Resident Records. Documentation verified that R1’s legally authorized representative was acting on R1’s behalf.

On 09/14/2025, S1 confirmed the requested records had been sent. On 09/15/2025, LPA followed up with W1, who confirmed the records were received on 08/19/2025—approximately two months after the initial request. The preponderance of evidence demonstrates that the facility did not release records within a reasonable or timely manner. Therefore, the allegation is substantiated.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250627153453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083
VISIT DATE: 09/24/2025
NARRATIVE
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LIC9099 (Page 3)

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250627153453
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARYMOUNT VILLA RETIREMENT CENTER
FACILITY NUMBER: 015601083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2025
Section Cited
CCR
87468.2(a)(19)
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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...the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records...records shall be provided within two (2) business days...

This requirement was not met as records requested on 06/04/2025 were not released until 08/19/2025.
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Administrator shall submit a written detailed plan describing corrective action to ensure record requests including but not limited
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Based on record review and interviews, the licensee did not comply with the section cited above in by not submitting requested former resident's, R1's, records to law firm in a timely manner which poses a potential health, safety or personal rights risk to persons in care.

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 to current residents, former residents, authorized representatives and law firms for pending lawsuitsare processed and provided within regulatory timeframes and submit to CCLD by POC due date.
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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: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4