<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 09/11/2024
Date Signed: 09/11/2024 06:38:26 PM


Document Has Been Signed on 09/11/2024 06:38 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: 10DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH: Mariano Alatorre, Interim-AdministratorTIME COMPLETED:
07:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/11/24 around 2:50 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an annual Infection Control Inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Mariano Alatorre, Interim-Administrator (ADM) was telephoned by the staff member and arrived about 20 minutes later.

Facility has a COVID-19 and Emergency Disaster Plan. LPA reviewed five (5) resident files and four (4) staff files. LPA observed a sign-in log at the entry. LPA and ADM toured the facility including, but not limited to common areas, bathroom, kitchen, front and side pathways. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and garbage cans. ADM to add paper towels to shared bathroom. There is a surplus of PPE stored centrally located inside the facility that is accessible to all care staff. The facility's temperature was 75 degrees (F). Fire extinguisher was observed full and replaced during visit with newly tagged ones. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s) (Reviewed)
-Staff and Resident Roster

Continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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 6


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: 09/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued from LIC809...

-At 4:00 PM, LPA observed that all of the kitchen, bedroom and common areas do not have window screens attached.

-At 3:18 PM, LPA observed R1's anti-seizure medication unlocked on the kitchen table. S1 locked the medication during the visit.

Based on observation, deficiencies are cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, Appeal Rights, and a copy of this report provided to Mariano Alatorre, Interim-Administrator (ADM)

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/11/2024 06:38 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not locking R1's medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
1
2
3
4
S1 locked R1's medication during the visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/11/2024 06:38 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above by not providing window screens in the kitchen, bedrooms and common areas which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Licensee to update CCLD with a quote and provide photos when the screens are installed on or before POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6