019201054-11-7-2023-15-AS-YFLS-CY2NWR-20231129094956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201054
Report Date: 11/07/2023
Date Signed: 11/07/2023 11:33:15 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/31/2023 and conducted by Evaluator Paris Watson

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20231031165312

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: 9	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Facility telephone is in disrepair

INVESTIGATION FINDINGS:

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On 11/07/2023 at 10:30 AM Licensing Program Analysts (LPA) P. Watson arrived unannounced to conduct a complaint investigation for the above allegation. LPA met with Administrator, Ferdinand Gutierrez, and explained the purpose of the visit.

During the course of the investigation, LPA toured facility and interviewed staff.

It was alleged that Facility telephone is in disrepair, based on interview with Administrator the facilities telephone was in disrepair for about 5 (five) days and was recently fixed. Administrator stated that they believe there were internet problems causing the phones to be in disrepair. Some of the residents have personal cell phones and were able to communicate with family members while the facility telephone was not operable, for the resident who does not have a personal cell phone their family members were unable to speak to them unless they called the Administrator and/or owner.

Report continues on 9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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-20231031165312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
	VISIT DATE: 11/07/2023

NARRATIVE

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Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20231031165312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR	FACILITY NUMBER: 019201054
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/10/2023 Section Cited CCR 87311	1 2 3 4 5 6 7	87311 Telephones All facilities shall have telephone service on the premises... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Deficiency cleared during visit, Administrator stated that the facility telephone was repaired about 3 (three) days ago and is operable. LPA called the facility telephone and confirmed it is working.
	8 9 10 11 12 13 14	Based on interview the licensee did not have telephone service for the residents which poses/posed a potential Health, Safety or Personal Rights risk to persons in care. Administrator stated that the phone was in disrepair for about 5 (five) days due to internet problems	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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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