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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 06/28/2023
Date Signed: 06/28/2023 06:57:46 PM


Document Has Been Signed on 06/28/2023 06:57 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) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 12DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Ferdinand Gutierrez/Administrator TIME COMPLETED:
07:00 PM
NARRATIVE
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While at the facility investigating two complaints (Control #'s 15-AS-20230626085047 and 15-AS-20230626143338), Licensing Program Analyst (LPA) Delmundo observed the following while conducting inspection with Ferdinand Gutierrez, administrator:
1. Front entrance door and 2 of the residents' rooms do not have auditory signals. The exit doors in the kitchen and family room's auditory signals broken. Resident (R1) was able to AWOL unnoticed by the staff.
2. Strong smell of urine. The administrator stated that resident (R2) who has dementia and incontinent is refusing care.
3. Used mattress, big piece of rolled carpet in the front yard, and pieces carpet in the side yard.
4. Grass cutter, shovel and rake in unlocked storage in the side yard.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of correction by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties.

Deficiencies plan and proof of correction were discussed with administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form 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: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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


Document Has Been Signed on 06/28/2023 06:57 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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2023
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(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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Administrator stated will have auditory signals installed. Pictures to be submitted by 6/29/23,
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-Based of observation, the licensee did not comply with the section above, for entrance and exit doors not having auditory signals which posed immediate risk to persons in care,
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Type A
06/29/2023
Section Cited
CCR87309(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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Administrator locked the storage,
In addition, administrator to do in-service training, and submit copy of training topic with attendees signatures by 6/29/23,
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-Based on observation, the licensee did not comply with the section for having the storage in the side yard not locked which poses immediate safety risks 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: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/28/2023 06:57 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: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sthe safety and well-being of residents, employees and visitors.anitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety
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Adminstrator to have the yard cleaned, and, submit pictures by 7/12/23.
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-This requirement is not met as evidenced by:
-Based o observation, the licensee did not comply with the section above for the soiled mattress & carpet in the yard which pose potential risks to person in care,
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Type B
07/12/2023
Section Cited
CCR87625(b)(3)

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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator stated will find placement for the resident. Proof to be submitted by 7/12/23.
Staff to continue to encourage the resident to be assisted in incontinence care while placement is pending.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section for facility having a strong smell of urine which poses personal rights risk 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: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3