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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 07/27/2023
Date Signed: 07/27/2023 06:44:49 PM


Document Has Been Signed on 07/27/2023 06:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:MORI MANORFACILITY NUMBER:
019201054
ADMINISTRATOR:GUTIERREZ, FERDINANDFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 12DATE:
07/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH: Ferdinand Ferdie' Gutierrez/AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day, July 27, 2023 at 12:30 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA was granted entry by staff, Rosa Maria Munoz. LPA called and spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, and informed the purpose of visit. Administrator arrived after several minutes. The other 2 staff. Maria Manjarez and Beatriz Munoz, arrived at around 1:00 pm.

On July 6, 2023, LPAs Delmundo and Fontanilla observed Medication Administration Record for May 2023 showed Insulin was administered by staff but not for June and July 2023; however, this medication was last filled 6/21/23. This medication is for resident (R4) and LPAs interviewed staff (S3) who stated she administered the insulin in May and didn't do the administration in June and July. However, during today's visit. July 27, 2023, in the presence of the administrator S3 stated she didn't administer the insulin but signed the May 2023 MAR.

Also on July 6, 2023, LPAs requested for the following documents to be submitted by July 20,2023:
1. LIC9282 Infection Control Plan - this document has not been submitted as of this day.
2. Proof of $3M liability insurance coverage - administrator showed to LPA the insurance coverage for Manor Manor facility; however, the licensee on the document is not that of Mori Manor, LLC which is the current licensee.

On this day, July 27, 2023, LPA observed staff (S1) working at the facility, and S1 is not fingerprint cleared and associated to this facility. LPA verified, and S1 and adminstrator stated S1 started working July 24, 2023. Staff Schedule effective July 24, 2023 also showed S2 on the schedule. LIC500 Personnel Report dated July 18, 2023 showed S2 was emplored 9/2022. Guardian Portal showed S2 has fingerprint clearance but not associated to this facility.

......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $400.00 civil penalty is assessed for section 87355(e)(1) for S1 who is not fingerprint cleared, and $250.00 for repeat violation of section 87355(e)(2) within 12 month period.

Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator.

Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/27/2023 06:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required....
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Administrator have the staff go for fingerprinting while LPA is still at the facility.
Administrator to read the Regulation and will not allow the staff to work until claared and associated. Proof to be submitted by 7/28/23.
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... by the Department
-This requirement is not met as evidenced by:
-Based on observation, interview and Guardian Portal check, the licensee did not comply with section above for having S1 work without fingerprint clearance.
This is a repeat violation.
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Type A
07/28/2023
Section Cited
CCR87465(e)

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87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file.....
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Administrator to check with the resident's physician if the medication is still needed. If still needed, to have a licensed professional administer; otherwise, obtain a discontinued order. Proof to be submitted by 7/28/23.
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-This requirement is not met as evidenced by:
-Based on observation and interview, the licensee did not comply with the section above for R4 who has insulin but no file and/or record of doctor's order. Insulin was not administered and facility does not have discontinued order. It's not clear it the med is still needed.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2023 06:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance ...

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Corrected.
Administrator submitted the LIC9182 on this day.

A $250.00 is assessed on this day,
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This requirement is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above for S2 who is not associated to this facility.
This is a repeat violation within 12 month period. First violation was issued on 7/18/23.
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Type B
08/10/2023
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General; (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
-This requirement is not met as evidenced by:
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Administrator to in-service the staff, and submit copy of traing topic with attendees signatures by 8/10/23.
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-Based on records review, the licensee did not comply with the section above for staff affixing initial on R4's MAR but the medication was not administered.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/27/2023 06:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
87470(c)

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87470 Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

-This requirement in not met as evidenced by:
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Administrator to developed a plan and submit copy by 8/10/23.
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-Based on interview and records review, the licensee did not comply with the section above for not having an Infection Control Plan which poses potentiall health risk to persons in care.
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Type B
08/10/2023
Section Cited
CCR1569.605

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§1569.605 Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, .... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three
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Licensee to obtain insurance coverage, and submit proof by 8/10/23.
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million dollars ($3,000,000) in the total annual aggregate.....
-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section for not having insurance coverage under licensee's name.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/27/2023 06:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2023
Section Cited
CCR
1569,69(b)

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§1569.69 Employees assisting residents with self-administration of medication; training requirements
(b) Each employee who received training and passed the examination... and who continues to assist with the self-administration of medicines, shall also complete four hours..
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Administrator to have the staff trained and submit proof by 8/10/23.
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 of in-service training on medication-related issues in each succeeding 12-month period.
-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section for S3 not having the required hours of annual medication training,
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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