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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:22:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MARY'S MANORFACILITY NUMBER:
015600392
ADMINISTRATOR:SUNDERRAJ, MARYFACILITY TYPE:
740
ADDRESS:3156 PUTTENHAM WAYTELEPHONE:
(510) 565-1479
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 4DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Deogracias ConchaTIME COMPLETED:
03:30 PM
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On 09/10/2021 at 2:20pm, Licensing Program Analyst (LPA) A. O'Hollaren arrived unannounced to conduct Infection Control Inspection. LPA met with Staff Deogracias Concha and explained the purpose of the visit. Licensee Mary Sunderraj was called.

During the inspection, LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed PPE, food and paper supplies are sufficient. Hand sanitizer is provided at facility entryway. Common areas are disinfected daily.

During record review, LPA observed facility has a copy of Mitigation Plan on file.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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