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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 10/24/2023
Date Signed: 10/24/2023 06:30:12 PM


Document Has Been Signed on 10/24/2023 06:30 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) 600-3840
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 9DATE:
10/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ferdinand Gutierrez/Administrator TIME COMPLETED:
06:30 PM
NARRATIVE
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On this day, October 24, 2023 at 9:35 am, Licensing Program Manager (LPM) Fong and Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on August 31, 2023. LPA met with staff Maria Manjarez, and informed the reason for visit. LPA also met with other staff, Blesilda Yamat, and Beatriz Munoz. LPA called and spoke over the phone with Ferdinand 'Ferdie' Gutierrez, administrator, who gave permission to have Maria Manjarez be with LPA during inspection. Administrator arrived at around 10:00 am.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. Hot water temperature in one of the bathrooms was tested and measured at 112.9 degrees Fahrenheit.

LPA reviewed 1 residents' (R2) file.

LPA observed the following:
-at 9:57 am, medications and wound cleanser unlocked in R1's room.
-at 9:58 am, smoke detector in R1's room removed from the ceiling..
-at 10:04 am, scissors, wound cleanser in R2 and R3's room.
-at 10:11 am. shovel in the side yard
-at 10:12 am, wall texture repair agent and rake in unlocked storage on the side yard.
-at 10:14 am, protruding uncovered drain about 3 to 4 inches in height in the side yard.
-at 10:17 am, weed killer unlocked in the cabinet in the foyer next to the kitchen where food supplies are kept.

....continued on 809C (page 2)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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: 10/24/2023
NARRATIVE
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Page 2

-at 10:45 am, mouse droppings in closet where heater is located.
-at 12:37 pm, resident's (R2) LIC9172 Functional Capability Assessment indicated R2 can reposition not consistent with LIC602A Physician's Report which showed R2 is bedridden. Preplacement Appraisal indicated ambulatory. R2's bed has half bed rails but no doctor's order on file.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds.

Civil penalties are assessed for the following:
1. $1,000.00 for fire safety violation # 87203. This is a repeat violation; first citation was issued on 6/28/23.
2. $250.00 for repeat violation of # 87465(h)(2) Incidental Medical and Dental Care for unlocked medications. First citation was issued on 7/18/23.
3. $250.00 for repeat violation of # 87309(a) Storage Space for unlocked storage with wall texture repair. agent and rake are kept, shovel in the side yard, weed killer in cabinet without lock in the foyer. Citations were issued on 6/28/23 and 7/06/23.
4. $250.00 for repeat violation # 87303(a) Maintenance and Operation for mouse droppings and protruding drain pipe. Citations were issued on 6/28/23 and 7/18/23.
5. $250.00 for repeat violation of # 87506(a) for LIC9172 and Appraisal not consistent with LIC602A. First citation was issued on 7/18/23.
6. $250.00 for repeat violation of # 87458(b)(5) Medical Assessment for LIC602A indicating R2 is bedridden. First citation was issued on 7/18/23.
Civil penalties will continue until corrected.

Deficiencies and civil penalties were discussed with the administrator. Administrator has to leave at 3:50 pm and authorized the pm staff, Rosamaria Munoz to sign and receive this report.

Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2023 06:30 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
-This requirement is not met as evidenced by:
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Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 10/25/23.

A $1,000.00 civil penalty is assessed today.
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-Based on observation and interview, the licensee did not comply with the section above for smoke detectors in R1's room removed which poses immediate safety risk to person in care.
Civil penalty is assessed.
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Type A
10/25/2023
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications..(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.
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Staff took and locked the medications.
Administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23.

A $250.00 civil penalty is assessed,
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-This requirement is not met as evidenced by:
-Based on observation. the licensee did not comply with the section above for medications unlocked in R1's room which poses immediate health and/or personal rights risks to persons in care.
This is a repeat violation.
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 10/24/2023 06:30 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
-This requirement is not met as evidenced by:
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Staff put shovel and weed killer in the storage and lock the storage,
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23.

A $250.00 civil penalty is assessed,
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-Based on observation, the licensee did not comply with the section above for unlocked storage, shovel in the side yard, weed killer in cabinet without lock in the foyer, wound cleanser in cabinets without lock, and scissors. These pose immediate health and safety risks to persons in care. This is a repeat violation.
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2023 06:30 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation


87303 Maintenance and Operation
(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.
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Administrator called Pest Control company to provide service. Proof of service to be submitted by 11/07/23.
In addition, administrator to do the following and submit proof by 11/07/23:
1. Have the mouse droppings cleaned-up and submit picture.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above for mouse droppings and protruding drain pipe which pose potential safety risks to persons in care. This is a repeat violation.
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2. Have the protruding pipe fixed and submit picture.

A $250.00 civil penalty is assessed,
Type B
11/07/2023
Section Cited
CCR87608(a)(3)

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87608 Postural Supports
(a) ....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.......
-This requirememt is not met as evidenced by:
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Administrator to obtain doctor's order and submit copy by 11/07/23.
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-Based on record review, the licensee did not comply with the section above for R2's half bed rails without doctor's order on file which poses potential personal rights risk to person in care.
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 10/24/2023 06:30 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87506(a)

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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 administrative location readily available to facility staff and to licensing agency staff
-This requirement is not met as evidenced by:
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Administrator to have R2 seen by primary care physician (pcp) and update the documents accordingly. Copies of updated Appraisal and LIC9172 to be submitted by 11/07/23.

A $250.00 civil penalty is assessed.
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-Based on record review, the licensee did not comply with the section above for R2's LIC9172 and Appraisal indicated ambulary, which are not consistent with LIC602A which showed bedridden. These pose potential safety and/or personal rights risks to person in care. This is a repeat violation.
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Type B
11/07/2023
Section Cited
CCR87458(b)(5)

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87458 Medical Assessment (b) The medical assessment shall include, .. (5) The determination whether the person is ambulatory or nonambulatory ... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both.
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Administrator to have R2 seen by pcp and have the LIC602A updated and copy to be submitted by 11/07/23.

A $250.00 civil penalty is assessed.
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-Based on record review, the licensee did not comply with the section above for R2's LIC602A indicated bedridden which poses potential safety and/or personal rights risks to persons in care.
This is a repeat violation,
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 10/24/2023 06:30 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87555(b)(24)

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87555 General Food Service Requirements: (b) The following food service requirements shall apply:
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.
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Staff removed and locked the weed killer.
Administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/07/23.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above for keeping the weed killer in the cabinet where food supplies are kept which poses potential health and/or personal right rsks to persons in care,
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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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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