019201054-7-17-2023-15-AS-KHOS-CU9MQA-20230731094823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201054
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:56:53 PM

Unsubstantiated

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
07/07/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230707155046

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: 10	DATE:	07/17/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff do not ensure medication cabinet is locked.
Staff do not ensure facility is free from pests.
Staff left a resident in bed for an extended period of time.
Staff do not ensure resident common areas are free from hazards.
Staff do not ensure hazardous chemicals are inaccessible to residents.

INVESTIGATION FINDINGS:

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On 7/17/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegations above and deliver findings. LPA met with Ferdinand Gutierrez, Administrator and explained the purpose of the visit.

During the visit LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard.

Staff do not ensure medication cabinet is locked. LPA observed the medications were locked in a closet in the kitchen.

Staff do not ensure facility is free from pests. LPA observed a few flies in the facility and no screen on a kitchen window. LPA advised ADM to purchase insect spray that is safe for indoor use.

Report continues on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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-20230707155046

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: 07/17/2023

NARRATIVE

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Report continues from LIC9099

Staff left a resident in bed for an extended period of time. LPA interviewed ADM who stated all the non-ambulatory residents are taken out of bed to be toileted daily and as needed. LPA interviewed R1 and R2 who were both in their beds in their rooms. R1 stated she gets up every day to do her leg exercises and eat her meals. R1 also stated that her roommate (R4 who was sleeping) also gets up everyday and socializes with the other residents. R2 stated he wants to get out of bed more but did not blame the staff. R2’s personal choice is to stay in bed. LPA could not interview R3 as he was sleeping. LPA interviewed S1 and S2 who both stated the they get the residents up every day to eat their meals, shower and socialize. S1 and S2 also stated that it is hard to get R2 out of bed because he likes to stay in bed.

Staff do not ensure resident common areas are free from hazards. LPA observed all common areas to be free from hazards.

Staff do not ensure hazardous chemicals are inaccessible to residents. LPA observed that the cleaning supplies and laundry detergent were both locked and inaccessible to residents.

LPA investigated the complaints alleging staff do not ensure medication cabinet is locked, staff do not ensure facility is free from pests, staff left a resident in bed for an extended period of time, staff do not ensure resident common areas are free from hazards and staff do not ensure hazardous chemicals are inaccessible to residents. We have found that the complaints are unsubstantiated.

Although the allegations may have happened or are 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 conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC9099 (FAS) - (06/04)

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