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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600392
Report Date: 09/17/2025
Date Signed: 09/17/2025 03:42:10 PM

Document Has Been Signed on 09/17/2025 03:42 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
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: 6DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Satvinder Kaur, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 09/17/2025 at 9:10 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Care Staff, Satvinder Kaur, and explained the purpose of the visit. Administrator, Mary Sunderraj, gave authorization on the phone for staff to sign the report.

LPA toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 bedrooms in total of which 4 bedrooms are occupied by the residents, 1 bedroom is occupied by staff, and one office. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents shared bathroom was measured at 107.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors in operating condition during visit. Fire extinguisher was last serviced on 11/06/2024. Emergency Disaster Plan was last posted on 09/03/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/11/2025.

At 10:27 AM, LPA reviewed 6 residents records. At 10:58 AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 12:30 PM, LPA reviewed 4 samples of residents’ medications.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 15
Document Has Been Signed on 09/17/2025 03:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/17/2025 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR
FACILITY NUMBER: 015600392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having carbon monoxide detector in the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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The Administrator agrees to purchase a carbon monoxide detector and install it. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having lysol wipes in the office, disinfectant spray in the hallway, and Tide Pods in resident's room which poses an immediate safety risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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The Administrator agrees to remove the items and self-certify the regulation. Proof of correction will be sent to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 09/17/2025 03:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/17/2025 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR
FACILITY NUMBER: 015600392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having both of the residents' bathroom uncleaned, R5's room with a strong urine ordor, broken patio furnitures in the backyard which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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The Administrator agrees to maintained the bathroom, R5's room, and have a bulk pick up for the patio furniture. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having staff training within the last year completed by S3 and S4 which poses a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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The Administrator agrees to have staff training and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 09/17/2025 03:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/17/2025 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR
FACILITY NUMBER: 015600392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(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
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Based on interview and observation, the licensee did not comply with the section cited above by having a half bed rail for R1 without a doctor's order which poses a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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The Administrator agrees to obtain a doctor's order for R1's half bed rail and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87465(a)(8)
If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having a first aid kit which posesd a potential safety risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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The Administrator agrees to purchase a first aid kid and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2025 03:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/17/2025 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR
FACILITY NUMBER: 015600392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(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
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications such as eyedrops, Miralax, Gummies, Tums, Levothyroxine, Ointment, etc., in all the residents room which poses an immediate safety risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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The Administrator agrees to lock the medications and self certify the regulation. Proof of correction will be sent to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2025 03:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/17/2025 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MARY'S MANOR
FACILITY NUMBER: 015600392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not having S4's file for review which poses a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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2
3
4
The Administrator agrees to send proof of S4's file to CCLD by POC date.
Type B
Section Cited
CCR
87211(a)(1)
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not reporting to licensing of an incident that occured with R3 back in January 2025 which posed a potential safety risk to persons in care.
POC Due Date: 10/02/2025
Plan of Correction
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The Administrator agrees to self certify the regulation and send proof to CCLD by POC 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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


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: 09/17/2025
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/03/2025:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Infection Control Plan

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:


At 9:15 AM, LPA observed both bathrooms not cleaned and R5's room with a strong urine odor.

At 9:17 PM, LPA observed broken patio furniture in the backyard.

At 9:29 AM, LPA observed Lysol wipes in the office, disinfectant spray in the hallway, and Tide Pods in resident's room unlocked and accessible to residents in care.

At 9:45 AM, LPA observed unlocked medications such as eyedrops, Miralax, Gummies, Tums, Levothyroxine, Ointment, etc., in all the residents’ room.

At 10:30 AM, first aid kit was not observed.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
Page: 14 of 15
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: 09/17/2025
NARRATIVE
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Continue from LIC809-C...

At 12:30 PM, an interview with staff revealed that R3 had an incident and was not reported to licensing.

At 1:06 PM, observation and interview revealed that the facility does not have a carbon monoxide detector.

At 1:16 PM, a record review showed that the facility did not have updated training for S3 and S4 on file.

At 1:41 PM, interview with staff stated that R1 does not have a doctor's order for the half bedrail.

At 1:45 PM, S4’s personnel file was not at the facility.


The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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