Mary's Manor
What is an RCFE with Memory Care?
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
3156 Puttenham Way · Fremont, 94536
Record last updated April 20, 2026.
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Quick facts
Memory care context
Mary's Manor is a California-licensed Residential Care Facility for the Elderly (RCFE) with a memory care designation, licensed for 6 beds. California Title 22 requires facilities serving dementia residents to meet specific standards under §87705 and §87706, covering individualized care plans, staff training in dementia care, and resident supervision protocols. CDSS records show 5 citations under §87705 or §87706 (dementia-care regulations) at this facility. The inspection history includes 6 reports on file with 30 total deficiencies: 11 Type A citations (actual harm to residents) and 19 Type B citations (potential for harm). The most recent inspection was January 16, 2025. The elevated count of Type A deficiencies warrants careful inquiry during any visit.
Questions to ask on your tour
Based on Mary's Manor's state inspection record.
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?
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?
With 30 total deficiencies across 6 inspections, what systemic changes has operator Mary Sunderraj made to reduce recurring compliance issues?
Given the 6-bed capacity, what is the staffing ratio during overnight hours, and how do you ensure continuous supervision for residents with dementia who may wander or need redirection?
The most recent inspection in January 2025 identified additional deficiencies — which of those remain under a plan of correction, and when is the next state follow-up scheduled?
State records
California CDSS · Community Care Licensing Division- License number
- 015600392
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Sunderraj, Mary
Inspections & citations
6
reports on file
30
total deficiencies
11
Type A (actual harm)
5
dementia-care citations
Other visitJanuary 16, 2025Type A9 deficiencies
Inspector notes
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.
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.
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.
(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.
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.
(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.
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 …
(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 subdivisi…
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.
(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.
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.
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:
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.
(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.
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.
(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:
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.
(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, an…
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.
Other visitOctober 3, 2024No deficiencies
Inspector: Patricia Manalo
Inspector notes
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.
InspectionSeptember 19, 2024No deficiencies
Inspector: Lori Alexander-Washington
Inspector notes
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.
InspectionAugust 25, 2023Type A14 deficiencies
Inspector: Lori Alexander-Washington
Inspector notes
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.
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fi…
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.
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fi…
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.
(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.
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.
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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.
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Priva…
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.
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms s…
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.
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (…
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.
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude car…
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.
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as…
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.
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
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.
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).
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.
(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.
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.
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility an…
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.
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care …
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.
InspectionAugust 26, 2022Type A4 deficiencies
Inspector: Liridon Fici
Inspector notes
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..
(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.
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
(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.
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.
(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…
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.
(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.
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.
InspectionSeptember 10, 2021Type A3 deficiencies
Inspector: Liridon Fici
Inspector notes
On today’s date, at 2:45PM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an Annual Infection Control Visit. LPA and LPM was greeted by Care Staff, Deogracia Concha at front door entrance. Shortly after, Licensee, Mary, Sunderraj arrived to facility. During the inspection, LPA and LPM toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA and LPM observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA and LPM observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. Common areas are disinfected frequently throughout the day. Water temperature is measured at 105.4 degrees F. Fire extinguisher was last serviced on 4/5/2021. Facilities room temperature is at 75. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA and LPM observed facility has a copy of their Infection Control Plan on file. 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 on Lic809-C The following Deficiencies were observed during visit: 1. At 2:50pm, LPA and LPM observed Medication and Knives unlocked and accessible to residents in care. 2. At 2:50pm, LPA and LPM observed during record review 6 out of 6 residents that do not have appraisal needs/service plans in their file. 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. Exit interview conducted with licensee, appeals rights given and copy of this report provided.
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
Based on observation, the licensee did not comply with the section cited above by not locking up knifes which were stored in an unlocked cabinet which poses an immediate health and safety risk to persons in care. POC Due Date: 08/27/2022 Plan of Correction 1 2 3 4 Deficiency Cleared Licensee locked up knifes in cabinet.
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Based on observation, the licensee did not comply with the section cited above by having medication cabinet unlocked and accessible to residents in care which poses an immediate health and safety risk to persons in care. POC Due Date: 08/27/2022 Plan of Correction 1 2 3 4 Deficiency cleared Licensee locked up medication in cabinet.
87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
Based on observation, record review, the licensee did not comply with the section cited above by not having residents Appraisal needs/service plans updated in their file which poses a potential health and safety risk to persons in care. POC Due Date: 09/09/2022 Plan of Correction 1 2 3 4 Licensee agreed to complete Appraisal needs/service plan and to submit it to CCL by POC due date.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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