Community Care Licensing

Document Has Been Signed on 07/18/2023 09:10 PM - It Cannot Be Edited

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:	07/18/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Ferdinand Gutierrez/Administrator		TIME COMPLETED:	09:15 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
	VISIT DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87465(f)(1)

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for not having LIC9020 Register of Facility Clients/Residents which poses/posed a potential health,or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to complete a LIC9020 and submit copy by 8/01/23.

Type B

Section Cited

HSC

1569.153(a)

(a) Establishment and posting of the facility’s policy regarding theft and investigative procedures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for not posting facility's Theft and Loss Policy which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to post the policy, and submit picture by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the following: (a) pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard; (b) mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard; (c) broken window blinds and protruding cable wires in room # 2. These pose a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator had the yards clean. Administrator to have the window blinds replaced with new one and removed the protruding cable. Pictures to be submiited by 8/01/23, A $250.00 civil penalty is assessed for repeat violation. First citation was issued on 6/28/23.

Type B

Section Cited

CCR

87303(i)

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for resident not having signal system or call button which pose a potential health, safety and/orr personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to purchase call button, and submit by 8/01/23 proof of purchase and pictures.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, licensee did not comply with the section cited above for not posting Complaint poster which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to post the poster in the prominent place and submit picture by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type A

Section Cited

CCR

87355(e)(1)

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 by the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for S1 not fingerprint cleared which poses an immediate safety and/or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Administrator to have S1 fingerprinted and associated. In addition, administrator not to allow S1 to work until cleared and associated. Proof to be submitted by 7/20/23. A $500.00 civil penalty is assessed.

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the insulin in the refrigerator which poses an immediate health and safety risks to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Staff locked the item. In addition, administrator to in-service the staff, and submit copy of training topic with attendees signatures by 7/19/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, licensee did not comply with the section cited above for 1 staff with no CPR/First and 4 staff with expired CPR/First Aid certiicates on file which posed a potential safety and/or personal rights risks to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Corrected. Staff completed the training.

Type B

Section Cited

CCR

87355(e)(2)

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 as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for staff (S6) not associated to this facility which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff associated and submot proof by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

HSC

1569.695(c)

§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and reord review, the licensee did not comply with the section cited above for not conducting disaster driill which poses a potential safety risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to conduct drills, and submit proof by 8/01/23.

Type B

Section Cited

HSC

1569.269(a)(2)

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above for having cameras installed that capture audio which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Corrected. Administrator removed all the camera.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and rord review, the licensee did not comply with the section cited above for R4 and R6 not having records which pose a potential health, safety and/or personal rights risks to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to complete the records, and submit self-certification by 8/01/23 stating records were completed.

Type B

Section Cited

CCR

87608(a)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for not having doctor's order for R2's half bed rails which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to obtain doctor's order, and submit copy by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87458(b)(1)

87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R5 not having TB test on file which poses a potential health risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to schedule an appointment, and submit copy of test by 8/01/23.

Type B

Section Cited

CCR

87458(b)(5)

87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews and record review, the licensee did not comply with the section for R7 who is non-ambulatory but LIC602A Physician's Report indicated ambulatory which poses a potential health and safety riisks to person in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator stated he'll have the LIC602 Physician's Report updated. Copy to be submitted by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

HSC

1569.625(b)(2)

§1569.625 Staff training; legislative findings; contents (b) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.1569.69(a) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for 4 staff not having the required annual training which poses a potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the training and submit proof by 8//01/23.

Type B

Section Cited

CCR

87411(a)

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..........Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview and review of staff schedule, the licensee did not comply with the section cited above for not having sufficient staff which poses a potential health, safety and/or rsonal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator stated he'll have the staffing increased. Copy of staff schedule to be submitted by 8/01/23.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type B

Section Cited

CCR

87307(a)(3)

87307 Personal Accommodations and Services (a) ...... The following provisions shall apply (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for not having paper towels for residents use for drying hands in 2 bathrooms which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Administrator to provide paper towels in paper towel holders. Pictures to be submiitted by 8/01/23.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023