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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 01/16/2025
Date Signed: 01/16/2025 10:08:16 AM

Document Has Been Signed on 01/16/2025 10:08 AM - 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 MANORFACILITY NUMBER:
015600392
ADMINISTRATOR/
DIRECTOR:		SUNDERRAJ, MARYFACILITY TYPE:
740
ADDRESS:3156 PUTTENHAM WAYTELEPHONE:
(510) 565-1479
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 5DATE:
01/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mary Sunderraj, Administrator TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 01/16/2025, at 9:00 AM Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding deficiencies that was observed during annual visit on 09/19/2024. LPAs met with Caregiver, Satvinder Kaur and explained the purpose of the visit. Satvinder phoned, Licensee/Administrator, Mary Sunderraj, to inform. Administrator came shortly.

During the annual inspection conducted on 09/19/2024, the facility was issued a citation on failure to provide doctor's order for use of half rails for R2, R3, and R4 with a Plan of Correction due on 10/10/2024.

During the visit, Administrator stated that R2, R3, and R4 do not need the half rails and removed the half rails.

Administrator stated that she will obtain a new Physician's Report for R4 if needed upon hospital discharge.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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