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Inspection visit

Routine inspection

MARY'S MANORLicense 01560039214 citations on this visit
14 citations recorded

Inspector’s narrative

What the inspector wrote

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... 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.

Citations

14 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.695(c)Type B

    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.

  • 87202(a)Type A

    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.

  • 87202(a)(2)Type A

    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.

  • 87307(a)(2)(D)Type B

    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.

  • 87309(a)Type A

    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.

  • 87458(b)(1)Type B

    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.

  • 87468(c)(1)Type B

    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.

  • 87468(c)(2)(A)Type B

    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.

  • 87507(c)Type B

    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.

  • 87606(c)Type B

    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.

  • 87608(a)(5)(A)Type B

    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.

  • 87632(d)(2)Type B

    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.

  • 87705(c)(5)Type B

    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.

  • 87705(f)(2)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the September 19, 2024 inspection of MARY'S MANOR?

This was a inspection inspection of MARY'S MANOR on September 19, 2024. 14 citations were issued: 4 Type A (serious) and 10 Type B.

Were any citations issued to MARY'S MANOR on September 19, 2024?

Yes, 14 citations were issued (4 Type A, 10 Type B). The first citation was for: "Based on interview and record review the licensee did not comply with the section cited above in by not having quarterly..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.