019201054-7-6-2023-15-AS-ADEO-CTH6TB-20230706210518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 07/06/2023
Date Signed: 07/06/2023 09:05:28 PM

Document Has Been Signed on 07/06/2023 09:05 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 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: 12	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Staff Maria Manjarez and Blesilda 'Blesie' Yamat		TIME COMPLETED:	09:10 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 this day, July 7, 2023 at 11:25 a.m, Licensing Program Analysts (LPAs) A. Delmundo and L. Fontanilla arrived unannounced to conduct an annual required inspection. LPA met with staff Maria Manjarez and Blesilda 'Blesie' Yamat, and informed the reason for visit. LPAs also met with Mauricio David. LPA Delmundo spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, who can not come to the facility, and gave permission to have Maria Manjarez to sign and receive this report. Facility has not submitted an LIC9282 Infection Control Plan. LPAs inspected the facility inside and out with Mauricio David and Maria Manjarez including but not limited to common areas, bedrooms, bathrooms, living room, kitchen, dining area, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced March 15, 2023. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the bathrooms was tested and measured at 107.6 degrees Fahrenheit. LPAs reviewed 5 residents and 5 staff files, and interviewed 3 staff and 2 residents. Facility does not handle residents' cash resources. LPAs observed the following: -at 11:45 am, faciliy's Theft and Loss policy not posted and no Complaint poster. -at 11:59 am, broken window blinds and protruding cable wires in room # 2. -at 12:01 and 12:19 pm. no paper towel in dispensers in 2 bathrooms. According to staff, supply of paper towel for the type of dispensers ran out .......continued on 809C (page 2)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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 4

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: 07/06/2023

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

Page 2

-at 12:02 pm, CALRes incontinence since and Pine Sol cleaning agent in the bathrooms.
-at 12:23 pm, pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard.
-at 12:33 pm, rake, mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard.
--at 12.43 pm, residents' medications in the refrigerator. Medication Administration Record for May 2023 showed Insulin was administered by staff but not for June and July 2023; however, this medication was last filled 6/21/23.
-residents (R1 and R3) who use cane and wheelchair respectively are in the rooms not fire cleared for non-ambulatory.
-At 3:00 pm, resident (R4) does not have records in the facility
-staff (S1) is not fingerprint cleared and associated to this facility.
-staff (S2 and S3) First Aid certificates on file expired 2018 and 2021.
-facility does not have file drill records. LPAs interviewed S3 who stated they don't do fire drill.

Licensee (Mori Manor, LLC) lost control of property when the property was sold, and licensee failed to inform Community Care Licensing.

Administrator to submit the following updated documents by July 20, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
4. Proof of $3M liability insurance coverage

....continued on 809C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/06/2023 09:05 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: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for Pine Sol & CALRes in the bathrooms and rake in the backyard which pose an immediate safety risks to persons in care. This is a repeat violation within 12 month. First citation as issued on 6/28/23. Civil penalty is assessed.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Staff locked the items. In addition, administrator to do in-service training and submit copy of training topic with attendees signatures by 7/07/23.

Type A

Section Cited

CCR

87204(a)

87204(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, licensee did not comply with the section cited above for 2 non-ambulatory residents in ambulatory only rooms which poses an immediate safety risk to persons in care. Civil penalty is assessed.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator stated he'll have the residents move to rooms fire cleared for non-ambulatory. Proof to be submitted by 7/07/23.

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 07/06/2023

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

Page 3

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500 and $250.00 civil penalties deficiency section #s 87204(b) and 87309(a) were assessed and will continue until corrected.

Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator over the phone..

Due to technical difficulties/issues, LPA to come back to issue citations for the rest of deficiencies observed and continue inspection.

Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments provided to Maria Manjarez.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4