015600392-8-25-2023-15-AS-LFII-CV2U9T-20230825152341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:23:51 PM

Document Has Been Signed on 08/25/2023 03:23 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
OAKLAND ASC, 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: 3	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Care staff, DEOGRACIAS CONCHA		TIME COMPLETED:	03:35 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 8/25/2023 starting at 12:00 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Deogracias, Concha, care staff and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) ambulatory residents, which all 6 may be non-ambulatory. Upon entry, LPA observed two (2) staff and three (3) residents present during inspection. Starting at 12:49 PM, LPA toured facility with care staff, including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 1 bedrooms is private, 2 rooms are shared, and 1 staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in clients’ common area bathroom was measured at 108.1 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 8/3/2021. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
	VISIT DATE: 08/25/2023

NARRATIVE

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Continued from Lic809

Starting At 1:27 PM, LPA reviewed 3 of 3 staff records. At 1:37 PM, LPA reviewed 3 of 3 resident' records. At 2:07 PM, LPA reviewed a sample of 3 of 3 residents' medication.

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.

1. At 12:57PM, LPA observed Medication and cleaning supplies unlocked and accessible to persons in care.

2. At 1:38PM, LPA observed R1, R2, and R3 with no needs and service plan on file

3. At 1:40PM, LPA observed R1, R2, and R3's Physicians reports dated for Year 2020 on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/1/2023:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610D Emergency Disaster Plan (9 Pages)
Liability Insurance
Surety bond
Updated facility sketch

Exit interview conducted with care staff, and a copy of this report provided along with appeal rights..

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/25/2023 03:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(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 by not locking up clearning chemicals like clorox bleach and spray located in the garage hallway which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2023
	Plan of Correction
1 2 3 4	Licensee agreed to keep all cleaning chemicals locked at all times. Deficiency cleared

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 residents stored medication located in the garage cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2023
	Plan of Correction
1 2 3 4	Licensee agreed to lock up all medication and to submit a photo of locked medications to CCL as proof by POC due date.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/25/2023 03:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR	FACILITY NUMBER: 015600392
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)(1)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not keeping and maintaining R1, R2, and R3's needs and service plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to maintain residents needs and service plans at all times in residents file and to submit a copy of residents needs and service plan to CCL by POC due date.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not maintaining and updating R1, R2, and R3's medical assessment yearly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to update residents medical assessment and to submit a copy to CCL by POC due date.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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