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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:15:18 PM

Document Has Been Signed on 10/03/2024 01:15 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MARY'S MANORFACILITY NUMBER:
015600392
ADMINISTRATOR/
DIRECTOR:		SUNDERRAJ, MARYFACILITY TYPE:
740
ADDRESS:3156 PUTTENHAM WAYTELEPHONE:
(510) 565-1479
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Satvinder Kaur, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/03/2024 at 11:00 AM Licensing Program Analysts (LPAs) L. Alexander and P. Manalo conducted an unannounced Case Management Plan of Correction visit regarding deficiencies that was observed during annual visit on 09/19/2024. LPAs met with Caregivers, Satvinder Kaur and Ravinder Singh and explained the purpose of the visit. Satvinder phoned, Licensee/Administrator, Mary Sunderraj, to inform. LPAs spoke with Mrs. Sunderraj who was not available to come to the facility. Mrs. Sunderraj gave authorization for Satvinder to sign report.

During the 09/19/2024, LPAs was informed by the Administrator that there was a Bedridden resident, R6, that was discharged from Kaiser Fremont Medical Center. Administrator stated that resident was only going to be at the facility for five (5) days. Licensee did not have a fire clearance for Bedridden. LPAs toured the facility and observed that there were six (6) residents at the facility. LPAs observed that R6 has moved out.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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