Community Care Licensing

Document is an Amendment of Original Document on 10/03/2024 12:42 PM

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 in by having a lock latch on gated fence which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Administrator removed lock during visit. Deficiency cleared.

Type A

Section Cited

CCR

87202(a)(2)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having a fire clearance for Bedridden which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Administrator will submit facility sketch for new fire inspection for bedriddn room.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in by not having Tide Laundry Pods and Clorox wipes inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Administrator will self-certify that they read the regulation and will comply moving forward.

Type A

Section Cited

CCR

87705(f)(2)

(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 in by not having unlocked medications and vitamins inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Administrator will self-certify that they read the regulation and will comply moving forward.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

CCR

87468(c)(1)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. 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 in by not having personal rights posters posted in the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will send a photo of poster hung in facility to CCLD by POC date.

Type B

Section Cited

CCR

87307(a)(2)(D)

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (D) Not more than two residents shall sleep in a bedroom. 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 in by having three (3) residents sharing 1 (one) bedroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will read the regulation and self-certify that they understand the regulations. Move one of the residents to another bedroom that is not over capacity. Send a photo to CCLD by POC date of room change.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 in by not having PUB 475 poster posted in facility entry way which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will send a photo to CCLD a poster posted by POC date.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not having an medical assessment for R6 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator to send a copy of medical assessment to CCLD by POC date.

Type B

Section Cited

CCR

87507(c)

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above in by not having an Admission Agreement on file for R6 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will send a copy of Admissions Agreement to CCLD by POC date.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 10/03/2024 01:18 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/03/2024 12:43 PM

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above in by not having quarterly fire drills conducted by staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will send fire drill with participants name and self certify that they read and understand the regulation moving forward. Will send certifications to CCLD by POC date.

Type B

Section Cited

CCR

87606(c)

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above in by not having a fire clearance, supporting documents to care for Bedridden and LIC200 on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator agree to submit an LIC 200 with facility sketch to CCLD by POC date. Immediate Civil Penalty $500.00 assessed today. Resident moved out. Deficiency cleared.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in by not having doctor's orders for 1/2 bed rails/hospital beds postural/mobility support for R2-R6 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will send copies of doctor's orders for R2-R6 bed rails to CCLD by POC date.

Type B

Section Cited

CCR

87632(d)(2)

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in by not sending notification of hospice R1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will read and self certify the regulation and send Initiation of Hospice Care Services for R1 to CCLD by POC date.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

Document Has Been Signed on 09/19/2024 04:22 PM - It Cannot Be Edited

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2024

Type B

Section Cited

CCR

87705(c)(5)

(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 as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above in by not having updated medical assessments and Appraisal Needs and Services (ANS) for R2-R6 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator will submit updated Physician's Reports (LIC602A) and ANS to CCLD by POC date.

Section Cited

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

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 725-7919 LICENSING EVALUATOR NAME: Lori Alexander-Washington TELEPHONE: (510) 285-3934 LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
	VISIT DATE: 09/19/2024