015601402-8-9-2021-15-AS-KHOS-C6FLVX-20210901090617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601402
Report Date: 08/09/2021
Date Signed: 08/09/2021 01:13:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200428133851

FACILITY NAME:	MORI MANOR		FACILITY NUMBER:	015601402
ADMINISTRATOR:	FERDINAND GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	1476 164TH AVENUE		TELEPHONE:	(510) 276-6167
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	14	CENSUS: 9	DATE:	08/09/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Unexplained bruising on resident.

INVESTIGATION FINDINGS:

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On 08/09/2021 at 10:00 AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the above allegation. LPAs spoke with July Francis Yambao, Caregiver. Ferdinand Gutierrez, Administrator arrived at 10:50 AM and LPAs explained the reason for the visit.

This complaint allegation was accepted by the Department’s Investigation Branch (IB) as a full investigation, (IB) report case #CD1520-04072. Based on record reviews and interviews by the Department, R1 moved from Mori Manor and was placed at another licensed facility on 4/23/2020. Staff at current facility observed numerous bruises on R1’s breasts and arms. Staff from Mori Manor confirmed there were bruises on R1 before being moved to the new facility.

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200428133851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 015601402
	VISIT DATE: 08/09/2021

NARRATIVE

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Continued from LIC9099.

Mori Manor Staff could not explain where the bruising came from and why medical attention was not obtained. R1 was unable to be interviewed as a part of this investigation due to the diagnosis of Dementia.

Based on the department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the LIC9099D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted. A copy of this report and appeal rights was emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200428133851

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 015601402
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/11/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2) To be accorded safe... accommodations... This requirement was not as evidence by:	1 2 3 4 5 6 7	Licensee agreed to have an authorized vendor provide training for all staff on personal rights. Licensee will schedule training by 8/16/2021 and submit proof of completion by 9/10/2021.
	8 9 10 11 12 13 14	Based on investigation , licensee did not comply with the section cited which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	A formal conference with CCLD will be scheduled at a later time. $500.00 immediate civil penalty is assessed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC9099 (FAS) - (06/04)

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