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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601083
Report Date: 12/29/2025
Date Signed: 12/29/2025 06:21:10 PM

Unsubstantiated


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
12/15/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251215162420
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:
12/29/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dolly Rizvi, Executive Director TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee is financially abusing resident in care.
INVESTIGATION FINDINGS:
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On 12/29/2025 at 12:00 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPAs met with Executive Director, Dolly Rizvi and explained the purpose of the visit.

During the investigation, LPAs collected the following documents: the facilities LIC 500 and residents roster. LPA also obtained and reviewed Resident one's (R1's) LIC602 (Medical assessment), Progress notes, Eviction Notice, admissions agreement, Invoice of room fees, Incident reports (month of July-December 2025), Pre-admission appraisal and Appraisal Needs and Services Plan. LPAs interviewed the Complainant, staff, and W1.

Continued to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
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 2
Control Number 15-AS-20251215162420
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: 12/29/2025
NARRATIVE
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Continued from LIC9099.

Allegation: Licensee is financially abusing resident in care.

Finding: Unsubstantiated

Based on interviews with staff and W1 revealed that R1 receives monthly income from Supplemental Security Income (SSI) and the remaining income was provided by the family. Interview with complainant indicated that R1 was being charged private room rate when R1 did not request to be in a private room. There was a lack of evidence that licensee is financially abusing R1.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.



No deficiencies are being cited on this date.

Exit interview conducted with Dolly Rizvi and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2