<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601402
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:07:56 AM



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
06/30/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200630145749
FACILITY NAME:MORI MANORFACILITY NUMBER:
015601402
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 9DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Gladys Salguero, CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure resident's have a sufficient amount of food.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/25/2021 at 10:10AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Gladys Salguero, Caregiver and explained the reason for the visit. LPAs spoke with Administrator, Ferdinand Gutierrez and he gave approval for Caregiver to sign documents.

During the investigation on 8/9/2021, LPAs toured the facility’s kitchen and garage. LPAs observed that facility did not have 7-day non-perishable or 2-day perishable foods available for the residents. LPAs observed ½ gallon of milk, condiments, a bag of thawed chicken, 4 bags of frozen green beans, some can goods and bread. The freezer located in the garage contained 2 boxes of impossible burgers. No other foods were observed by LPAs.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20200630145749
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: 08/25/2021
NARRATIVE
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 LIC9099.

Based on LPAs observation during 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.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/30/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200630145749

FACILITY NAME:MORI MANORFACILITY NUMBER:
015601402
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 9DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Gladys Salguero, CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication.

Staff speaks inappropriately to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/25/2021 at 10:10AM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the above allegations. LPAs met with Gladys Salguero, Caregiver and explained the reason for the visit. LPAs spoke with Administrator, Ferdinand Gutierrez and he gave approval for Caregiver to sign documents.

During the investigation, LPAs conducted interviews with the facility staff, obtained and reviewed physician’s report, facility notes, incident reports, and appraisal/needs and services plan for R1. Reviewing physician’s report and interviews with facility staff indicated R1 was able to administer insulin if cued or reminded. No forthcoming information provided by reporting party.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20200630145749
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: 08/25/2021
NARRATIVE
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 LIC9099.

On the allegation staff speaks inappropriately to residents. Based on LPA’s interviews with four (4) of nine (9) residents. Three (3) of the residents stated staff speaks appropriately most of the time. Two (3) of the residents would not respond. Two (2) resident was sleeping and one (1) wasn’t at the facility.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conduct and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200630145749
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: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2021
Section Cited
CCR
87555(b)(26)
1
2
3
4
5
6
7
87555 Requirements (b)... food service requirements shall apply:26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained... This requirement was not met as evidence by:


1
2
3
4
5
6
7
Administrator agreed to purchase perishables and non-perishables for facility and submit photos and receipt to CCLD by POC date.
8
9
10
11
12
13
14
Based on LPA's observation Licensee did not comply with section cited above, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5