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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 06:22:10 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
11/12/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251112180321
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:
02:00 PM
MET WITH:Dolly Rizvi, Executive Director TIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Staff are physically abusing resident in care.
Staff are emotionally abusing resident in care.
INVESTIGATION FINDINGS:
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On 12/29/2025 at 2:00 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with Executive Director, Dolly Rizvi and informed her the reason for visit.

During investigation, LPAs obtained and reviewed the following documents: Resident Roster and the LIC500 (Personnel Report). LPAs also collected and reviewed the following documents for Resident one (R1, R2 and R3): Progress notes (September-November 2025), Incident Reports (September-November 2025), LIC602 (physician's report), Appraisal Needs and Services Plan, Identification and emergency contact form and staff Contact Information. LPAs interviewed six (6) residents and four (4) staff members.

Continued on 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-20251112180321
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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Allegation: Staff are physically abusing resident in care.

Finding: Unsubstantiated

Based on the investigation, interviews with staff revealed that they have not witnessed or heard about any staff members physically or emotionally abusing any residents in care. Interviews with residents reveal that they have not experienced any staff members physically or emotionally harming them or others at the facility.

Allegation: Staff are emotionally abusing resident in care.

Finding: Unsubstantiated

Based on interviews with residents, it was revealed that they have not experienced any staff members emotionally abusing them or witnessed any staff members emotionally abusing any residents. Interviews with staff revealed that they have not witnessed or heard about any staff members emotionally abusing residents in care.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are 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