015600392-8-26-2022-15-AS-LFII-CHP2T7-20220826174016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 08/26/2022
Date Signed: 08/26/2022 05:42:01 PM

Document Has Been Signed on 08/26/2022 05:42 PM - It Cannot Be Edited

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 MANOR		FACILITY NUMBER:	015600392
ADMINISTRATOR:	SUNDERRAJ, MARY		FACILITY TYPE:	740
ADDRESS:	3156 PUTTENHAM WAY		TELEPHONE:	(510) 565-1479
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Licensee, Mary, Sunderraj		TIME COMPLETED:	05:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On today’s date, at 2:45PM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an Annual Infection Control Visit. LPA and LPM was greeted by Care Staff, Deogracia Concha at front door entrance. Shortly after, Licensee, Mary, Sunderraj arrived to facility. During the inspection, LPA and LPM toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA and LPM observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA and LPM observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. Common areas are disinfected frequently throughout the day. Water temperature is measured at 105.4 degrees F. Fire extinguisher was last serviced on 4/5/2021. Facilities room temperature is at 75. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA and LPM observed facility has a copy of their Infection Control Plan on file. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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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Document Has Been Signed on 08/26/2022 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking up knifes which were stored in an unlocked cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/27/2022
	Plan of Correction
1 2 3 4	Deficiency Cleared Licensee locked up knifes in cabinet.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having medication cabinet unlocked and accessible to residents in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/27/2022
	Plan of Correction
1 2 3 4	Deficiency cleared Licensee locked up medication in cabinet.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
	VISIT DATE: 08/26/2022

NARRATIVE

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Continued on Lic809-C

The following Deficiencies were observed during visit:

1. At 2:50pm, LPA and LPM observed Medication and Knives unlocked and accessible to residents in care.

2. At 2:50pm, LPA and LPM observed during record review 6 out of 6 residents that do not have appraisal needs/service plans in their file.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with licensee, appeals rights given and copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 08/26/2022 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above by not having residents Appraisal needs/service plans updated in their file which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Licensee agreed to complete Appraisal needs/service plan and to submit it to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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