019201054-6-15-2023-15-AS-KHOS-CSYHWJ-20230620063338

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201054
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:03:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/11/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230411143331

FACILITY NAME:	MORI MANOR		FACILITY NUMBER:	019201054
ADMINISTRATOR:	GUTIERREZ, FERDINAND		FACILITY TYPE:	740
ADDRESS:	1476 164TH AVENUE		TELEPHONE:	(510) 276-6167
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	14	CENSUS: 10	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident not given medications
Resident not fed
Staff not providing enough water to resident
Resident not repositioned
Resident's chuck pad and clothing not changed

INVESTIGATION FINDINGS:

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On 06/15/23 at 12:45 PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident not given medications
Investigation Finding: Unsubstantiated
During investigation, staff confirmed with LPA that resident (R1) refused to take all her medications from 12/06/21 until 04/09/23. Review of resident (R1) centrally stored medication logs and medication administration records show R1’s documented medication administration record (MARs) refusals. Review of other residents (R2, R3, R4) MARs show residents received assistance daily from staff in taking their prescribed medications Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not given medications is unsubstantiated.
Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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-20230411143331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/15/2023

NARRATIVE

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Allegation: Resident not fed
Investigation Finding: Unsubstantiated
During investigation, staff (S1) confirmed with LPA that resident (R1) refuses to eat hot food prepared for breakfast, lunch and dinner. S1 stated R1 only wants to eat cereal and drink water. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not fed is unsubstantiated.

Allegation: Staff not providing enough water to resident

Investigation Finding: Unsubstantiated
During investigation, staff (S1) stated that they provide resident (R1) with water daily. R1’s constant refusal to take her medications and drink enough water has led her to be sent to the hospital several times for constipation and bowel impaction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff is not providing enough water to resident is unsubstantiated.

Allegation: Resident not repositioned

Investigation Finding: Unsubstantiated
During investigation, staff (S1) confirmed with LPA that she provided care and supervision to resident (R1) at the facility. S1 stated she cleaned R1, changed her chuck pad daily and repositioned her when allowed by R1. ADM confirmed with LPA that R1 constantly refused to be cleaned, eat food prepared for residents and take her medications. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident is not repositioned is unsubstantiated.

Allegation: Resident’s chuck pad and clothing not changed
Investigation Finding: Unsubstantiated
During investigation, staff (ADM, S1) confirmed with LPA that resident (R1) constantly refused to get cleaned and chuck pads changed. S1 stated she changes R1’s chuck pads and clean her daily when allowed by R1. However, R1 doesn’t want to be touched and told S1 that her bed was eating her private parts up. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident’s chuck pad and clothing is not changed is unsubstantiated.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

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