019201054-8-11-2023-15-AS-ADEO-CULUSS-20230811155048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:50:58 PM

Document Has Been Signed on 08/11/2023 03:50 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 MANOR		FACILITY NUMBER:	019201054
ADMINISTRATOR:	GUTIERREZ, FERDINAND		FACILITY TYPE:	740
ADDRESS:	1476 164TH AVENUE		TELEPHONE:	(510) 600-3840
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	14	CENSUS: 14	DATE:	08/11/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Ferdinand 'Ferdie' Gutierrez/Administrator		TIME COMPLETED:	03:55 PM

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	Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and granted entry by Maria Manjarez, staff. LPA called and spoke over the phone with Ferdinand Gutierrez, administrator, and informed the reason for visit. Administrator arrived after about 15 minutes. On 7/18/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 8/01/23. Administrator submitted the POCs either after the deadline. failed to submit and/or POCs are incomplete. Civil penalties are assessed on this day, 8/11/23. 1. Deficiency section 87458(b)(5) - LIC602A Physician's Report was submitted on 8/10/23. Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23)= $900.00 2. Deficiency section 87465(f)(1) - LIC9020 Register of Facility Clients/Residents has not been submitted. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 3. Deficiency section 87303(i) - proof of purchase of signal system or call button, and picture not submitted up to this day, 8/11/23. Facility does not have working call buttons as of this day, 8/11/23. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 4. Deficiency section 1569.695(c) - proof that disaster drills is conducted has not been submitted, Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 5. Deficiency section 1569.625(b)(2) - copies of staff training submitted; however, the 8 hours required annual training was not satisfied. Administrator submitted only 2 hours training and no proof of 4 hours required postural support, restricted health conditions and hospice care training. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. .....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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: 08/11/2023

NARRATIVE

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6. Deficiency section 87411(a) - administrator submitted the LIC500 Personnel Report on 8/10/23; however, it is incorrect and still shows insufficient staff coverage. LPA responded to the administrator, and on this day, 8/11/23, LPA discussed the corrections needed. Copy of corrected LIC500 provided by administrator on this day.
Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00
7. Deficiency section 87506(a) - administrator submitted copies of LIC625 Appraisal/Needs and Services Plan and LIC602A on 8//10/23. On this day, 8/11/23, LPA reviewed residents (R4 and R6) files and observed R4's updated LIC602A is still not on the file. Administrator put the LIC602A on R4's file.
Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23) = $900.00
8. Deficiency section 87307(a)(3) - administrator has not submitted proof that bathrooms has paper towels in paper towel holders. On this day, 8/11/23, LPA inspected the bathrooms and observed no paper towels.
Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected.

On 7/27/23, LPA Delmundo issued citation for deficiency section 1569.605 with POC to submit proof of $3M liability insurance coverage by 8/10/23. Administrator has not submitted the POC up to this date, 8/11/23.
Civil penalty = $100.00/day x 1 day (8/11/23) = $100.00 and will continue until corrected.

Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction forms, 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: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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