Marymount Villa Retirement Center

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that the cabinet in the common area on level 3 is missing a handle, dresser and floor in room 315 is in disrepair, which poses a potential safety risk to persons in care.

87309 Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that disinfectants and cleaners like Lysol sprays, Petroleum Jelly, Razor, and A+D Ointment, were in an unlocked cabinet in the common area where residents have access which poses an immediate safety risk to persons in care.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such... attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above in that the water temperature was measured at 95.7 degrees Fahrenheit in a random sample of residents shared bathroomswhich poses a potential health and safety risk to persons in care.

87219 Planned Activities(i) The licensee shall implement reasonable interventions in order to ensure the safety of all residents utilizing indoor and outdoor areas and take precautions to prevent residents from unsafe wandering and elopement, as defined in Section 87101, Definitions. Such precautions may not conflict with residents' personal rights as specified in Section 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities.This requirement is not met as evidenced by: Based on record review and interviews, the facility did not meet the requirement above by staff neglecting to ensure that R1 who is a memory care resident was being supervised during group activities with assisted living residents in the common area which led to R1's elopement. There was also not a process in place to assure residents safety during activities which posed an immediate safety risk to residents in care.

Personnel Requirements-General 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above by not having sufficient and competent number of staff to meet R1's care needs. Executive Director states that staff were not aware of R1's elopement and they did not complete head counts until after the activity which resulted in R1 having eloped for approximately 40 minutes before the facility was aware which is a potential safety and personal rights risks to residents in care.

1569.655 Increase in fee rates for elderly residents; 90 days’ written notice...(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives... This requirement is not met as evidience by: Based on record review, licensee did not comply with the section cited above by not providing 90 days written notice for increase rate which poses a potential health and safety risk to the persons in care.

Eviction Procedures. (a) The licensee may evict a resident for one or more of the reasons listed... (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above by not providing an explanation in the eviction notice which poses a potential health and safety risk to the persons in care.

Based on record review, the licensee did not comply with the section cited above in that 0 out of 5 staff members did not have first aid certification on file which poses an immediate health and safety risk to persons in care.

87612 Restricted Health Conditions(a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services:(11) Wound care as specified in Section 87631. Based on files review and interview the Licensee did not comply with the section cited above by R1 having an unstageable wound residing in the facility, which poses an immediate health and safety risk to persons in care.

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. 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.

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. 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.

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: 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.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidenced by:-Based on interview with ED/ADM there were no incident reports submitted to CCLD for the emergency exit blockages on the 3rd, 4th and 5th floors of the facility which poses a potential safety and risks to person in care.

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by staff failing to keep emergency exit doors unobstructed which posed an immediate health and safety risk to residents in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by:-Based on interviews, the licensee did not comply with the section above when the resident's room was not cleaned which posed personal rights risk to person in care.

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidence by: Based on interviews facility staff admits that fire exits were being temporarily blocked to redirect residents which posed a potential safety violation to resident in care.

87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.-This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above when staff did not attend to R1 nor call the facility nurse when R1 sustained injury which posed an immediate health, safety and/or personal rights risks to person in care.

General Food Service Requirements. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not ensuring R1 is following specified diet which poses a potential health and safety risk to the persons in care.

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.

Admission Agreements . A refund of at least 60 percent of the preadmission fee...shall be provided if the resident leaves the facility for any reason during the second month of residency. This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing refund of 60% of preadmission fee which poses a potential personal rights violation to the persons in care.

Additional Personal Rights of Residents in Privately Operated Facilities. To have prompt access to review all of their records and...records shall be provided within two (2) business days... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing requested records which poses a potential personal rights violation to the persons in care.

Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s...care needs as identified in his/her current appraisal. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not having sufficient staffing which poses a potential health and safety risk to the persons in care.

Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not following the care plan which poses a potential health and safety risk to the persons in care.

Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by failing to seek timely medical attention for R1's open wound which poses an immediate health and safety risk to the persons in care.

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...and that appropriate assistance is provided... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not observing R1's open wound which poses a potential health and safety risk to the persons in care.

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ....and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s...... -This requirement is not met as evidenced by:-Based on records review and interview, the licensee did not comply with the section above. R1 who has dementia does not have reappraisals for 2020 and 2021which posed potential health and safe risks to person in care.

General Food Service Requirements. Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C)... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having freezer temperature at 10-15 degrees F which poses a potential health and safety risk to the persons in care.

Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical, ...safety...needs... This requirement is not met as evidence by: Based on interview, licensee did not comply with the section cited above due to resident AWOL which poses a potential health and safety risk to the residents in care.