019201054-6-28-2023-15-AS-KHOS-CTLLBX-20230710083728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201054
Report Date: 06/28/2023
Date Signed: 06/28/2023 07:11:26 PM

Substantiated

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
06/26/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230626085047

FACILITY NAME:	MORI MANOR		FACILITY NUMBER:	019201054
ADMINISTRATOR:	GUTIERREZ, FERDINAND		FACILITY TYPE:	740
ADDRESS:	1476 164TH AVENUE		TELEPHONE:	(510) 276-6167
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	14	CENSUS: 12	DATE:	06/28/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ferdinand Gutierrez/Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff uninstalled smoke detector from resident's room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannouced to investigate the above allegation. LPA was granter entry by Maria Manjarez, staff. Ferdinad Gutierrez, administrator, arrived after several minutes, LPA informed reason for visit.

LPA conducted inspection with Ferdinand Gutierrez and conducted interviews.

It was alleged that the smoke detector in one of the resident's room was beeping continously and was observed removed from the ceiling, LPA interviiwed the administrator who confirmed the detector was beeping and was removed about 2 weeks ago, LPA conducted inspection, and observed smoke detectors were removed from the ceiling in room #'s 1, 2, 3, 5 and 6, and family room.

....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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 3

Control Number 15-AS-20230626085047

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: 019201054
	VISIT DATE: 06/28/2023

NARRATIVE

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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed for fire safety violation and will continue for $100/day until corrected.

Deficiency, plan and proof of correction, and civil penalty were discussed with administrator.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230626085047

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: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/29/2023 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced byL	1 2 3 4 5 6 7	Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 6/29/23. A $500.00 civil penalty is assessed today.
	8 9 10 11 12 13 14	-Based on observation and interview, the licensee did not comply with the section above for removing the smoke detectors in 5 residents rooms and family room. Civil penalty is assessed.	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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

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