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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:47:33 PM


Document Has Been Signed on 04/12/2022 04:47 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: 9DATE:
04/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Gladys Salguero, CaregiverTIME COMPLETED:
05:00 PM
NARRATIVE
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On 4/12/22 at 1:05pm, Licensing Program Analyst (LPA) C Lin arrived unannounced to conduct a case management visit as a result of receiving a self-report dated on 4/7/2022 to indicate a resident developed wound in stage 3 while in care. LPA met with the caregiver Gladys Salguero and explained the purpose of the visit. Administrator Ferdinand Gutierrez was unavailable and authorized the caregiver on the phone to sign on this report.

At 1:10pm, LPA toured the facility and observed that the laundry room door was let opened with a long brown wood stick on purpose, laundry detergent was observed inside the laundry room. Staff stated that the dryer was missing a hose of exhausting heat when it was installed in February 2022, when the door was closed steam would be filled up the laundry room. Therefore, staff let the door open for about 2 hours every time when they did the laundry. 1 resident with Dementia and 1 resident with Cognitive issue were observed walking inside facility when the laundry room door was opened. Staff locked laundry room door during visit.

At 1:30pm LPA reviewed the file of resident who developed pressure injury while in care. Staff stated that resident was sent to emergency room in time manner when wound was noticed, home health nurse was ordered by resident's physician when discharging from hospital. LPA spoke with home health nurse and hospice nurse from the agency Health Flex to be confirmed that resident's wound has been monitored and in care. However, facility was unable to provide document of resident's changing condition and update appraisal/care plan. LPA spoke with Administrator on the phone, Administrator admitted that resident's care plan has not been updated.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.


Exit interview conducted with caregiver, LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/12/2022 04:47 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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia
(2) ...alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidenced by:
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Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed unlocked detergent in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
04/22/2022
Section Cited

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....

This requirement was not met as evidenced by:
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Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed appraisal/care plan has not been updated due to changing in condition.
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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) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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