Mary's Manor.
Mary's Manor is Ranked in the bottom 9% of California memory care with 27 CDSS citations on record; last inspected Sep 2025.
Small Memory Care Home in Fremont's Glenmoor Area, reviewed on public record.
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Compared to 152 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
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Mary's Manor has 27 citations on record. Know the moment anything changes.
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Citation history, plotted month by month.
27 deficiencies on record. Each bar is a month with a citation.
Finding distribution
27 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
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“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Mary's Manor's record and state requirements.
State records show 11 Type A deficiencies (actual harm citations) across 6 inspections — what specific incidents led to these citations, and what corrective actions were implemented after each one?
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Five citations under §87705 or §87706 (dementia-care regulations) appear in the inspection history — which specific dementia-care requirements were violated, and what training or procedural changes resulted?
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With 30 total deficiencies across 6 inspections, what systemic changes has operator Mary Sunderraj made to reduce recurring compliance issues?
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Every inspection visit, verbatim.
5 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-09-17Other VisitType A · 9 findings
Plain-language summary
During a routine annual inspection on September 17, 2025, inspectors found multiple safety and cleanliness issues: bathrooms were not cleaned and one resident's room had a strong urine odor; cleaning supplies, disinfectant spray, and laundry pods were left unlocked and accessible to residents; medications including eyedrops, laxatives, and heart medication were stored unlocked in residents' rooms; and the facility lacked a carbon monoxide detector. The inspection also identified problems with staff training records not being current, one incident that was not reported to licensing, a resident using a half bedrail without a doctor's order, and one staff member's personnel file not being at the facility.
“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 1 2 3 4 The Administrator agrees to purchase a carbon monoxide detector and install it. Proof of correction will be sent to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to remove the items and self-certify the regulation. Proof of correction will be sent to CCLD by POC date.”
“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 1 2 3 4 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.”
“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 1 2 3 4 The Administrator agrees to have staff training and send proof to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to obtain a doctor's order for R1's half bed rail and send proof to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to purchase a first aid kid and send proof to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to lock the medications and self certify the regulation. Proof of correction will be sent to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to send proof of S4's file to CCLD by POC date.”
“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 1 2 3 4 The Administrator agrees to self certify the regulation and send proof to CCLD by POC date.”
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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... 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 26 27 28 29 30 31 32 Continue from LIC809... 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... 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 26 27 28 29 30 31 32 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.
2025-01-16Other VisitNo findings
Plain-language summary
On January 16, 2025, inspectors conducted a follow-up visit to check on a previous problem found during the facility's annual inspection in September 2024, when the facility was cited for using half rails for three residents without a doctor's order. During the follow-up visit, the administrator confirmed that these three residents no longer need the half rails and had them removed, and stated that a new physician's report would be obtained if needed. No violations were found during this visit.
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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.
2024-10-03Annual Compliance VisitNo findings
Plain-language summary
This was a follow-up visit on October 3, 2024 to check on corrections from the facility's annual inspection in September, which had found that the facility lacked fire safety clearance for bedridden residents. During the follow-up visit, inspectors found that the bedridden resident who had been discharged from Kaiser Fremont Medical Center had since moved out, and no deficiencies were identified.
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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.
2024-09-19Annual Compliance VisitType A · 14 findings
Plain-language summary
This was a routine annual inspection conducted on September 19, 2024, and the facility was found to meet basic standards for safety, sanitation, and staffing—smoke detectors and carbon monoxide detectors were working, bathrooms and kitchen were safe and sanitary, lighting was adequate, and all staff had current first aid training. The inspector noted some paperwork deficiencies that required correction, including updated personnel records and insurance documentation to be submitted by late September 2024.
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
“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.”
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This is an amendment to an original LIC809 report issued on 09/19/24. On 09/19/2024 at 12:35 PM, Licensing Program Analysts (LPAs) L. Alexander and Patricia Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Licensee/Administrator, Mary Sunderraj and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) and hospice waiver for three (3). Administrator Certificate #60011363740 expired 06/28/2023. Administrator provided a copy of faxed re-certification on 05/24/2023. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of total 4 bedrooms which 4 bedrooms are occupied by the clients and a partitioned area bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/28/2023. Emergency Disaster Drill was last posted on 03/03/2024. First aid kit was observed to be complete. LIC809-C Continued... 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 26 27 28 29 30 31 32 LIC809-C Continued... 5 of 6 clients’ records were reviewed. 3 staff records were reviewed, and 3 of 3 have current first aid training and associated to the facility. The following deficiencies were observed (see LIC 809D) and 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. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/26/2024: LIC 500 Personnel Report LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 400 Affidavit Regarding Client/Resident Cash Resources LIC 402 Surety Bond LIC 610D Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Exit interview conducted. Appeal Rights and a copy of this report provided.
2023-08-25Annual Compliance VisitType A · 4 findings
Plain-language summary
During a routine annual inspection on August 25, 2023, inspectors found that medication and cleaning supplies were unlocked and accessible to residents, and that three residents did not have current care plans or physician reports on file (physician reports were from 2020). The facility was otherwise in good condition with adequate lighting, temperature control, working smoke and carbon monoxide detectors, and safety features like non-skid bathroom mats.
“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”
“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.”
“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.”
“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.”
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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 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 26 27 28 29 30 31 32 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..
1 older inspection from 2022 are not shown above.
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