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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:49:45 PM


Document Has Been Signed on 05/08/2024 04:49 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: 7DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mariano Alatorre/AdministratorTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Report (UIR) for resident (R1) submitted by the administrator to the Department, and forwarded by another LPA to LPA Delmundo on 5/02/24. UIR indicated that at around 8:30 am on 4/21/24, staff (S1) allowed R1 to hang out in the backyard. S1 went inside to get water and when S1 returned. R1 left using the side fence door. Administrator was called who went to look for R1 and called 9-1-1. R1 was returned by the police after at 10:50 am same day.

On 5/07/24, administrator submitted another UIR for R1. UIR indicated at around 2:30 pm on 5/03/24, staff (S2) called the administrator and informed that R1 ran away. Administrator gave instruction to S2 to call 9-1-1 and report R1 is missing. Police came to the facility and informed staff (S3) that R1 was found and will be transported to hospital. R1 was discharged back to the facility same day at around 10:45 pm.

On this day, 5/08/24, LPA met with Beatriz Munoz, staff, and informed the reason for visit. LPA called and spoke with the administrator over the phone. LPA conducted inspection with Beatriz Munoz. Administrator arrived after about 30 minutes. LPA also met with other staff, Maura White. LPA conducted interviews, and reviewed the documents obtained from the administrator.. Administrator and staff stated R1 didn't sustain any injuries during the 2 incidents. LIC602A Phyician's Report indicated R1 can leave the facility unassisted.

During today's visit, LPA observed the auditory signals on the front door and door in the common area at the back leading to the backyard were turned off.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. A $250.00 civil penalty is assessed for repeat violation within 12 month period and will continue for $100.00/day if not corrected.

......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: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 3


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: 05/08/2024
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Deficiency , plan and proof of correction and civil penalty were discussed with the administrator. Administrator has to leave, and authorized Maura White to sign and receive this report.

Also discussed was the updating of R1's LIC625 Appraisal/Needs and Services Plan. Copy to be submitted by 5/09/24.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Penalty Assessment, 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: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/08/2024 04:49 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87705(j)

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87705 (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

-This requirement is not met as evidenced by
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Auditory signals were turned on while LPA was at the facility.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/09/24.
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-Based of observation, the licensee did not comply with the section above in entrance/exit doors auditory signals turned off which posed immediate risk to persons in care,
This is a repeat violation within 12 month period. First citation was issued on 6/28/23.
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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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3