019201054-7-27-2023-15-AS-KHOS-CURR4V-20230816124210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201054
Report Date: 07/27/2023
Date Signed: 07/27/2023 07:06:08 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-20230626143338

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:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Ferdinand Ferdie' Gutierrez/Administrator		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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-Staff did not adequately supervise resident (R1) while in care.

-Staff do not maintain records regarding resident (R1) in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Ferdinand Gutierrez, administrator, and informed the reason for visit,

Allegation: Staff did not adequately supervise resident (R1) while in care.
It was alleged that R1 had been missing for over 12 hours and no staff realized R1 was gone until the next morning.

On 6/28/23 and 7/14/23, LPA interviewed staff (S1, S2, S3, S4 and administrator) who all stated R1 has AWOL behavior, The first time R1 went out of the facility, staff followed R1 and redirected back to the facility, R1 went AWOL again and unnoticed on June 22, 2023 and June 26. 2023. One of the staff stated R1 has gone missing on the night of June 25, 2023 and noticed R1 was missing the following day in the morning of June 26, 2023.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230626143338

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: 07/27/2023

NARRATIVE

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Staff filed missing person report to local law enforcement. Police reports confirmed R1 AWOLed on the said dates.

Based on information gathered, the preponderance of evidence has been met, therefore the allegation of 'staff did not adequately supervise resident (R1) while in care' is closed as substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Allegation: Staff do not maintain records regarding resident (R1) in care.
It was alleged that when law enforcement responded and went to the facility, the staff were not able to provide information for R1.

All staff interviewed stated R1 does not have record at the facility. During the 10-day initial visit on June 28, 2023, LPA asked the administrator for R1's file and administrator stated R1 has no record.

Based on information obtained, the preponderance of evidence has been met, therefore the allegation of 'staff do not maintain records regarding resident (R1) in care' is substantiated. Deficiency section 87506(a) was cited during annual inspection on July 18, 2023 with proof of correction to be submitted by 8/01/23.

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

Copy of this report, Appeal Rights, 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: 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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230626143338

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: 07/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/28/2023 Section Cited CCR 1569.312(a)	1 2 3 4 5 6 7	§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to do the following, and submit proof by 7/28/23: 1. Complete Appraisal/Needs and Services Plan. 2. In-service the staff.
	8 9 10 11 12 13 14	-Based on interviews and review of police reports, the licensee did not comply with the section above for R1 who was able to AWOL which posed immediate safety risk to person in care.	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: 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

LIC9099 (FAS) - (06/04)

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