Mori Manor

Continued from LIC9099. Allegation: Staff at the facility are not monitoring resident's blood pressure Finding: Unsubstantiated Interview with the reporting party (RP) revealed that the facility has not been monitoring R1's blood pressure (BP). Interview with S1 revealed that R1 has not requested for the staff to check their BP and they have not received a doctors order stating that it is required to monitor R1s BP. Interview with R1 revealed that they have not requested the staff to monitor their BP but would prefer staff to do it. LPA reviewed R1's medication list and doctor's orders and there were no instructions that BP has to be monitored and checked. Based on interviews and record review during visit, the allegation that staff at the facility are not monitoring resident's blood pressure was found to be unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Administrator gave authorization for Maria to sign today's report. Exit Interview conducted with Maria and copy of this report provided.

On 6/19/2025, at 2:45 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk conducted an unannounced Case Management health and safety check. LPAs met with Mariano Alatoree, Administrator and explained the purpose of the visit. The administrator currently holds a certificate (#6066221740) that expires on 9/25/2025. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of seven (7) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for residents is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared residents’ bathroom was measured at 105 degrees Fahrenheit. LPAs observed the following deficiencies: At 4:04 PM, LPAs observed unlocked medication in a resident room and unlocked medication in facility refrigerator. At 4:03 PM, LPAs observed scissors unlocked in a resident room and cleaning solutions and cleaning disinfectants in an unlocked laundry room. At 4:16 PM, LPAs observed facility did not pay outstanding licensing fees. At 4:17 PM, LPAs observed facility did not provide documents for administrator change. Continue to LIC809C. 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. The deficiencies were cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties Exit interview conduct. A copy of this report, Civil Penalty, and appeal rights provided.

On 9/30/2025 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection to follow up on renewal for conditional use permit (CUP). LPA met with Administrator, Mariano Alatorre and explained the reason for the visit. Planning Department, William Chin was also present during inspection. During visit, LPA toured the facility with Administrator and Planning Department. There was 12 residents and 3 staff present during inspection. LPA obtain additional information on the next steps in renewing the CUP. LPA will continue to follow up for the CUP renewal. Administrator will continue to update LPA on scheduled meetings and other changes. No deficiencies are being cited on this date. Exit interview conducted with Mariano Alatorre. A copy of this report provided.

On 4/12/22 at 1:05pm, Licensing Program Analyst (LPA) C Lin arrived unannounced to conduct a case management visit as a result of receiving a self-report dated on 4/7/2022 to indicate a resident developed wound in stage 3 while in care. LPA met with the caregiver Gladys Salguero and explained the purpose of the visit. Administrator Ferdinand Gutierrez was unavailable and authorized the caregiver on the phone to sign on this report. At 1:10pm, LPA toured the facility and observed that the laundry room door was let opened with a long brown wood stick on purpose, laundry detergent was observed inside the laundry room. Staff stated that the dryer was missing a hose of exhausting heat when it was installed in February 2022, when the door was closed steam would be filled up the laundry room. Therefore, staff let the door open for about 2 hours every time when they did the laundry. 1 resident with Dementia and 1 resident with Cognitive issue were observed walking inside facility when the laundry room door was opened. Staff locked laundry room door during visit. At 1:30pm LPA reviewed the file of resident who developed pressure injury while in care. Staff stated that resident was sent to emergency room in time manner when wound was noticed, home health nurse was ordered by resident's physician when discharging from hospital. LPA spoke with home health nurse and hospice nurse from the agency Health Flex to be confirmed that resident's wound has been monitored and in care. However, facility was unable to provide document of resident's changing condition and update appraisal/care plan . LPA spoke with Administrator on the phone, Administrator admitted that resident's care plan has not been updated. The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with caregiver, LIC809D, Appeal Rights and a copy of this report provided.

On 08/28/2025 at 11:30 AM, Licensing Program Analyst (LPA) Y. Brown arrived to conduct an unannounced annual 1-year required inspection. LPA met with care staff Shella Onia and explained the purpose of the visit. Shella phoned Administrator (AD) Mariano Alatorre who arrived around 12:15 pm. The administrator currently holds a certificate (#6066221740) that expires on 9/25/2025. The facility’s fire clearance was approved for fourteen (14) residents, (9) may be non-ambulatory. The facility has an approved hospice waiver of four (4). LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of seven (7) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the facilities kitchen was measured at 109.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. Smoke detectors and carbon monoxide combination were in operating condition during visit. Fire extinguisher was last purchased on 08/11/2025. First aid kit was observed to be complete. Continued on LIC809C. 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. LPA reviewed eight (8) resident records and six (6) staff records. LPA reviewed a sample of medication. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 07/15/2025 at 10:35 AM, Licensing Program Analysts (LPAs) Y. Brown and J.Clancy-Czuleger arrived unannounced to conduct a Case Management Inspection to follow up on an incident report that LPA Y. Brown received on 7/15/2025. LPAs met with facility staff and they called the Administrator. Administrator Mariano Alatorre arrived to the facility at 10:57 AM and LPA's explained the reason for the visit. The LPAs requested the resident (R1) records for review. LPAs reviewed and obtained a copy of R1's physician's report, after-visit summary notes from Eden Hospital, and R1's current and updated Appraisal needs and services plan. LPAs interviewed Administrator (AD) and discussed that R1 has a history of falls and there have been multiple incident of falls in the past at the facility none resulting in injury. AD stated that on 07/2/2025, R1 complained of pain on their right leg at night time. AD stated that R1 was experiencing cramps on their left leg and after consulting with R1's responsible party the facility staff gave R1 Tylenol. AD stated that the facility staff did not observe any swelling on the leg. AD stated on 7/3/2025, R1 continued having pain in their left leg and at around 11:34 AM, facility staff called Royal Ambulance for a non-emergency transport to Eden Hospital. AD stated that the facility staff did not see any swelling on R1's leg at this time either. AD stated that R1's daughter contacted the facility on 7/4/2025 and stated that R1 was getting discharged and that R1 obtained a small Tibula fracture. Continued on LIC809C. 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. AD stated that they believe the fracture could have occurred during transferring R1 on the hoyer lift. AD stated they have contacted R1's daughter and have been brainstorming different fall prevention ideas to help R1. AD stated that they are updating R1's Appraisal Needs and Services Plan to reflect R1's needs. During the visit, LPAs collected corrections of deficiencies from a case management visit on 6/19/2025 including S1's administrator certificate. LPAs also discussed the current status in the facilities CPU permit and the predicted timeline. LPAs may return at a later date. Exit interview conducted with Mariano Alatorre. A copy of this report provided.

On 8/28/2025 at 11:30 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a Case Management visit regarding an incident that was reported to CCLD on 7/15/2025 . LPA met with care staff Shella Onia and explained the purpose of the visit. Shella phoned Administrator (AD) Mariano Alatorre who arrived around 12:15 pm. Incident report for R1 was sent on 7/10/2025. LPA interviewed staff, obtained and reviewed a copy of R1's physician's report, after-visit s ummary notes, and R1's current and updated Appraisal needs and services plan. S1 stated that on 7/2/2035, R1 complained of pain in their right leg at nighttime. S1 stated that they consulted with R1's responsible party and the responsible party advised the facility not to call 9-1-1 and the facility staff gave R1 Tylenol. S1 stated that R1 continued having pain in their left leg and on 7/3/2025 at around 11:34 AM, facility staff called Royal Ambulance for a non-emergency transport to the Hospital. LPA observed the following deficiency: The facility did not immediately telephone 9-1-1 when R1 stated that they were experiencing pain. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.

On 6/17/2021 starting at 12:25pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a Pre-licensing visit. Upon arrival, LPA met with care staff, Gladys Salguero and contacted Licensee, Jene Snypes over the phone to explain the purpose of the visit. Administrator, Ferdinand Gutierrez later arrived at 1:05pm. LPA toured facility including but not limited to the resident bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. There is sufficient lighting throughout the facility. Residents rooms are equipped with the proper furniture and lighting. Resident rooms have proper bedding and linens for the resident's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher is in was observed fully charged. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. This is an existing facility and 2-day perishable and 7-day nonperishable are available for the clients. Upon arrival, LPA observed a for sale sign at the front yard of the facility. LPA inquired about the property over the phone with Licensee, and it was revealed that the facility is currently listed on the market. LPA will not be recommending for facility to be licensed at this time until issue has been resolved. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. Once issue is resolved, LPA will return to facility and complete COMP III. Exit interview conducted and a copy of this report provided.

On 6/19/2025 at 2:45PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct Case Management Inspection to follow up on renewal for conditional use permit (CUP) with Code Enforcement. LPAs met with Administrator, Mariano Alatorre and explained the reason for the visit. During visit, LPAs spoke with Administrator to obtain additional information on obtaining the CUP. Administrator was able to contact new applicant/licensee over the phone and LPAs were informed that new applicant/licensee is working with Code Enforcement to complete the corrections needed to obtain the CUP. LPAs obtained contact information for current and new applicant/licensee. LPAs may return at a later time. No deficiencies are being cited on this date. Exit interview conducted with Mariano Alatorre. A copy of this report provided.

On 2/3/2026 at 11:30 PM, Licensing Program Analysts (LPA) Y. Brown arrived unannounced to conduct a Case Management visit. LPA met with care staff Maria Manjarez. While LPA Y. Brown was conducting a complaint investigation (15-AS-20260128135521) on 2/3/2026, during file review and interview LPA discovered: 1. The facility did not obtain medication refills for R1 in a timely manner. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Administrator gave authorization for Maria to sign today's report. Exit interview conducted with Maria and a copy of this report and appeal rights provided.

While at the facility conducting a case management visit for the AWOL incidents, Licensing Program Analyst (LPA) observed during inspection and learned the following from interviews: 1. Overgrown weeds about 1 to 2 feet high in the backyard. 2. Bed frame, head board and bed rails in the side yard. 3. No planned activities. On 9/31/23, a Non-compliance Conference (NCC) was conducted with the licensee and one of the compliance plans was to have the administrator be present in the facility 40 hours per week. On this day, 5/08/24, LPA reviewed the schedule which showed the administrator is at the facility Monday through Friday from 5:00 pm to 8:00 pm and on-call on Saturdays and Sundays. LPA verified, and the administrator confirmed his schedule of work which is less than 40 hours/week. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for each of the repeat violation of deficiency section #'s 87405(a) and 87303(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Administrator has to leave and authorized Maura White to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of correction form, LIC421FC, and copy of this report provided.

On this day, October 24, 2023 at 9:35 am, Licensing Program Manager (LPM) Fong and Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on August 31, 2023. LPA met with staff Maria Manjarez, and informed the reason for visit. LPA also met with other staff, Blesilda Yamat, and Beatriz Munoz. LPA called and spoke over the phone with Ferdinand 'Ferdie' Gutierrez, administrator, who gave permission to have Maria Manjarez be with LPA during inspection. Administrator arrived at around 10:00 am. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. Hot water temperature in one of the bathrooms was tested and measured at 112.9 degrees Fahrenheit. LPA reviewed 1 residents' (R2) file. LPA observed the following: -at 9:57 am, medications and wound cleanser unlocked in R1's room. -at 9:58 am, smoke detector in R1's room removed from the ceiling.. -at 10:04 am, scissors, wound cleanser in R2 and R3's room. -at 10:11 am. shovel in the side yard -at 10:12 am, wall texture repair agent and rake in unlocked storage on the side yard. -at 10:14 am, protruding uncovered drain about 3 to 4 inches in height in the side yard. -at 10:17 am, weed killer unlocked in the cabinet in the foyer next to the kitchen where food supplies are kept. ....continued on 809C (page 2) 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 10:45 am, mouse droppings in closet where heater is located. -at 12:37 pm, resident's (R2) LIC9172 Functional Capability Assessment indicated R2 can reposition not consistent with LIC602A Physician's Report which showed R2 is bedridden. Preplacement Appraisal indicated ambulatory. R2's bed has half bed rails but no doctor's order on file. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Civil penalties are assessed for the following: 1. $1,000.00 for fire safety violation # 87203. This is a repeat violation; first citation was issued on 6/28/23. 2. $250.00 for repeat violation of # 87465(h)(2) Incidental Medical and Dental Care for unlocked medications. First citation was issued on 7/18/23. 3. $250.00 for repeat violation of # 87309(a) Storage Space for unlocked storage with wall texture repair. agent and rake are kept, shovel in the side yard, weed killer in cabinet without lock in the foyer. Citations were issued on 6/28/23 and 7/06/23. 4. $250.00 for repeat violation # 87303(a) Maintenance and Operation for mouse droppings and protruding drain pipe. Citations were issued on 6/28/23 and 7/18/23. 5. $250.00 for repeat violation of # 87506(a) for LIC9172 and Appraisal not consistent with LIC602A. First citation was issued on 7/18/23. 6. $250.00 for repeat violation of # 87458(b)(5) Medical Assessment for LIC602A indicating R2 is bedridden. First citation was issued on 7/18/23. Civil penalties will continue until corrected. Deficiencies and civil penalties were discussed with the administrator. Administrator has to leave at 3:50 pm and authorized the pm staff, Rosamaria Munoz to sign and receive this report. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.

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) 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 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.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit and met with Ferdinand Gutierrez, administrator, and informed the reason for visit. On 9/29/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 9/30/23; however, a dministrator submitted the POCs on 10/01/23. Civil penalties of $100.00 each for the following is assessed on this day, 10/24/23: 1. Section # 87705(1) Care of Persons with Dementia 2. Section # 87705(f)(2) Care of Persons with Dementia Deficiency section # 87458(a) Medical Assessment was also cited on 9/29/23 is being re-cited on this same day for failure to submit POC by 10/13/23: Deficiency section # 87463(c) Reappraisals - Administrator showed to LPA R2's LIC625 Appraisal/Needs and Services Plan which was completed on 10/09/23; however, administrator failed to submit the POC by 10/13/23. This deficiency is cleared on this day. Deficiencies and civil penalties were discussed with administrator who authorized staff, Rosamaria Munoz to sign and receive this report. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

On this day, September 29, 2023 at 12:05 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on August 31, 2023. LPA met with staff Maria Manjarez, and informed the reason for visit. LPA also met with other staff, Blesilda Yamat, and Pedro Rabulan. LPA spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, who gave permission to have Maria Manjarez be with LPA during inspection. Administrator arrived after above 3 hours. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. LPA reviewed 2 residents' file. LPA observed the following: -at 12:30 pm, 12:34 pm and 12:40 pm., weed and grass killer in the front yard, shave cream unlocked in the common bathroom, and shovel in the side yard respectively. -resident (R1) has 8 medications but no doctor's order on file. -resident (R2) has 8 medications listed on After Visit Summary dated July 24, 2023 provided by the administrator via email to LPA on July 27, 2023. This document has 8 medications listed; however, facility has only 5 medications on hand of which 2 have labels with strength and dosage different from the list, 1 (a PRN) no longer on the list. Vitamin B-12, melatonin and multi Vitamin were on the list but facility does have these. Vaccine is also listed but it's not clear if resident received the vaccine. .....continued on 809C 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 -R2's LIC602A signed by a Physician Assistant (PA-C) indicated mild cognitive impairment not consistent with document signed by Hospitalist (MD). R2's After Visit Summary indicated R2 to have a follow-up visit August 21, 2023. LPA verified with administrator, and administrator indicated he has not communicated with R2's case manager to schedule the appointment. -R2's LIC625 Appraisal/Needs and Services Plan is over a year old. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A civil penalty of of $250.00 for repeat violation of section: 87465(e), and will continue for $100.00/day if not corrected within due date. Deficiencies, plan and proof of corrections and civil penalty were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421FC Civil Penalty Assessment, and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and granted entry by Maria Manjarez, staff. LPA called and spoke over the phone with Ferdinand Gutierrez, administrator, and informed the reason for visit. Administrator arrived after about 15 minutes. On 7/18/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 8/01/23. Administrator submitted the POCs either after the deadline. failed to submit and/or POCs are incomplete. Civil penalties are assessed on this day, 8/11/23. 1. Deficiency section 87458(b)(5 ) - LIC602A Physician's Report was submitted on 8/10/23. Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23)= $900.00 2. Deficiency section 87465(f)(1 ) - L IC9020 Register of Facility Clients/Residents has not been submitted. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 3. Deficiency section 87303(i) - proof of purchase of signal system or call button, and picture not submitted up to this day, 8/11/23. Facility does not have working call buttons as of this day, 8/11/23. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 4. Deficiency section 1 569.695(c) - proof that disaster drills is conducted has not been submitted, Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. 5. Deficiency section 1569.625(b)(2) - copies of staff training submitted; however, the 8 hours required annual training was not satisfied. Administrator submitted only 2 hours training and no proof of 4 hours required postural support, restricted health conditions and hospice care training. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected . .....continued on 809C 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 6. Deficiency section 87411(a) - administrator submitted the LIC500 Personnel Report on 8/10/23; however, it is incorrect and still shows insufficient staff coverage. LPA responded to the administrator, and on this day, 8/11/23, LPA discussed the corrections needed. Copy of corrected LIC500 provided by administrator on this day. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 7. Deficiency section 87506(a) - administrator submitted copies of LIC625 Appraisal/Needs and Services Plan and LIC602A on 8//10/23. On this day, 8/11/23, LPA reviewed residents (R4 and R6) files and observed R4's updated LIC602A is still not on the file. Administrator put the LIC602A on R4's file. Civil penalty = $100.00/day x 9 days (from 8/02/23 to 8/10/23) = $900.00 8. Deficiency section 87307(a)(3) - administrator has not submitted proof that bathrooms has paper towels in paper towel holders. On this day, 8/11/23, LPA inspected the bathrooms and observed no paper towels. Civil penalty = $100.00/day x 10 days (from 8/02/23 to 8/11/23) = $1,000.00 and will continue until corrected. On 7/27/23, LPA Delmundo issued citation for deficiency section 1569.605 with POC to submit proof of $3M liability insurance coverage by 8/10/23. Administrator has not submitted the POC up to this date, 8/11/23. Civil penalty = $100.00/day x 1 day (8/11/23) = $100.00 and will continue until corrected. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction forms, and copy of this report provided.

On this day, August 31, 2023, a Non-compliance Conference was conducted. The existing deficiencies, problem areas in the operation of the facility, civil penalties, repeat violations and failure to submit proof of corrections were discussed. Present at the meeting were: 1. Regional Manager Isaac Taggart 2. Licensing Program Manager (LPM) Jeremy Fong 3 Licensing Program Analyst (LPA) Alicia Delmundo 4. Jene Snipes/Licensee 5. Ferdinand Gutierrez/Administrator 6. Dr Nandeesh Veerappa Deficiency is cited from Title 22 California Code of Regulations for administrator qualification. Additional civil penalty is issued on this day for failure to submit proof of corrections by plan of correction due date for $3M liabity insurance coverage (H&S Code 1569.605). This deficiency was cited on 7/27/23. A POC visit was conducted on 8/11/23 for failure to timely correct and with civil penalty will continue until corrected. CP = $100.00/day x 20 days (8/12/23 to 8/31/23) = $2,000.00 Deficiency and plan of correction were discussed. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and met with Ferdinand Gutierrez, administrator. LPA informed the reason for visit. On July 6, 2023, LPAs Delmundo and Fontanilla started the annual required inspection. Deficiency section 87204(a) was cited for having 2 non-ambulatory residents in ambulatory only rooms. Administrator stated he'll have the residents moved to rooms with fire clearance for non-ambulatory with proof of correction (POC) to be submitted by July 7, 2023. A civil penalty was assessed on July 6, 2023 which will continue until corrected. As of this day, July 18. 2023, administrator has not submitted the POC, LPA Delmundo conducted inspection and interviewed staff (S1) and administrator who both stated that resident (R3) was only moved on Tuesday, July 11, 2023. An additional civil penalty of $400.00 is assessed on this day for $100.00/day from July 8, 2023 to July 11, 2023 and was discussed with the administrator. Administrator has to leave, and authorized JulyFrancia Yambao, staff, to sign and received this report. Copy of this report, Appeal Rights and LIC421FC Civil Penalty Assessment provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and met with Ferdinand Gutierrez, administrator. LPA informed the purpose of visit. On 7/06/23, LPAs Delmundo and Fontanilla initiated an annual required inspection and issued citation for deficiency section 87309(a) with POC to be submitted by 7/07/23. Administrator submitted the POC only 7/11/23. A $400.00 civil penalty is assessed on this day, 7/27/23, for $100.00/day from 7/08/223 to 7/11/23. On 7/18/23, LPA Delmundo issued citation for deficiency section 87355(e)(1) for staff who was not fingerprinted with POC to be submitted by 7/19/23. Administrator submitted the POC only on this day, July 27, 2023. A $800.00 civil penalty is assessed for $100.00/day from 7/20/23 to 7/27/23. Deficiency section 1569.153(a) was cited for Theft and Loss Policy not posted with POC to be submitted by 8/01/23. On this day, LPA observed the Policy is posted. Exit interview conducted. Appeal Right, LIC421FCs Civil Penalties and copy of this report provided.

An Informal Conference was held on this day, July 13, 2023, via video conference. The purpose of this conference was to discuss non-compliance issues. The informal conference process was explained to the licensee, administrator, applicant for new license. Present at the meeting were: 1. Regional Manager (RM) Isaac Taggart 2. Licensing Program Manager (LPM) Jeremy Fong 3. Licensing Program Analyst (LPA) Alicia Delmundo 4. Jene Levine Snipes - Licensee 5. Ferdinand Gutierrez - Administrator 6. Dr. Nandeesh Veerappa - applicant for new license Issues discussed during the meeting: - Lost of control of property -Conditional permit -On-going facility issues and concerns .....continued on 809C 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 At the conclusion of this informal conference, licensee was informed of the following: 1. While application is still to be submitted, licensee is fully responsible for care and supervision of residents. 2. Conditional Use Permit has to be submitted to the Department. Exit interview conducted and copy of this report provided to licensee and administrator via e-mail.

Report continues from LIC9099 Staff left a resident in bed for an extended period of time. LPA interviewed ADM who stated all the non-ambulatory residents are taken out of bed to be toileted daily and as needed. LPA interviewed R1 and R2 who were both in their beds in their rooms. R1 stated she gets up every day to do her leg exercises and eat her meals. R1 also stated that her roommate (R4 who was sleeping) also gets up everyday and socializes with the other residents. R2 stated he wants to get out of bed more but did not blame the staff. R2’s personal choice is to stay in bed. LPA could not interview R3 as he was sleeping. LPA interviewed S1 and S2 who both stated the they get the residents up every day to eat their meals, shower and socialize. S1 and S2 also stated that it is hard to get R2 out of bed because he likes to stay in bed. Staff do not ensure resident common areas are free from hazards. LPA observed all common areas to be free from hazards. Staff do not ensure hazardous chemicals are inaccessible to residents. LPA observed that the cleaning supplies and laundry detergent were both locked and inaccessible to residents. LPA investigated the complaints alleging staff do not ensure medication cabinet is locked, staff do not ensure facility is free from pests, staff left a resident in bed for an extended period of time, staff do not ensure resident common areas are free from hazards and staff do not ensure hazardous chemicals are inaccessible to residents. We have found that the complaints are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.

On this day, July 27, 2023 at 12:30 p.m, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit. LPA was granted entry by staff, Rosa Maria Munoz. LPA called and spoke over the phone with Ferdinand Ferdie' Gutierrez, administrator, and informed the purpose of visit. Administrator arrived after several minutes. The other 2 staff. Maria Manjarez and Beatriz Munoz, arrived at around 1:00 pm. On July 6, 2023, LPAs Delmundo and Fontanilla observed 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. This medication is for resident (R4) and LPAs interviewed staff (S3) who stated she administered the insulin in May and didn't do the administration in June and July. However, during today's visit. July 27, 2023, in the presence of the administrator S3 stated she didn't administer the insulin but signed the May 2023 MAR. Also on July 6, 2023, LPAs requested for the following documents to be submitted by July 20,2023: 1. LIC9282 Infection Control Plan - this document has not been submitted as of this day. 2. Proof of $3M liability insurance coverage - administrator showed to LPA the insurance coverage for Manor Manor facility; however, the licensee on the document is not that of Mori Manor, LLC which is the current licensee. On this day, July 27, 2023, LPA observed staff (S1) working at the facility, and S1 is not fingerprint cleared and associated to this facility. LPA verified, and S1 and adminstrator stated S1 started working July 24, 2023. Staff Schedule effective July 24, 2023 also showed S2 on the schedule. LIC500 Personnel Report dated July 18, 2023 showed S2 was emplored 9/2022. Guardian Portal showed S2 has fingerprint clearance but not associated to this facility. ......continued on 809C 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 Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $400.00 civil penalty is assessed for section 87355(e)(1) for S1 who is not fingerprint cleared, and $250.00 for repeat violation of section 87355(e)(2) within 12 month period. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and LIC421FC Civil Penalty Assessments, and copy of this report provided.

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.

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.

On 4/28/22 approximately 9:25am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with caregiver Gladys Salguero and spoke with Administrator, Ferdinand Gutierrez on the phone, and explained the purpose of the visit. Administrator had submitted resident's Needs & Service Plan to CCL via email at 3:24pm on 4/22/22, however had LPA's email in error so LPA didn't received it. Administrator resubmitted it to LPA during visit. LPA obtained resident's note of changing in condition during visit. Administrator forgot to retrain staff for regulation, and admitted that the training would be provided and submitted to CCL today, 4/28/22, otherwise civil penalty will be issued. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.

On 06/15/23, while at the facility for another reason, Licensing Program Analyst (LPA) observed resident’s (R1) written documents (pre-appraisal report, admission agreement, physician’s report, needs & services plan, ID and emergency information) were not available for inspection at the facility. ADM stated R1 called 911 herself on 4/09/23 and was taken to ER hospital by ambulance. Staff gave paramedics R1's folder of documents containing her admission agreement, pre-appraisal/ appraisal reports, physician's report, incident reports, needs and services plan. ADM stated he was not able to locate R1’s missing folder at the hospital. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided.

On 4/19/22 approximately 1:50pm, Licensing Program Analysts (LPAs) C. Lin and K. Nguyen arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit. Administrator admitted that he has not submitted POC for 87705(f)(2). A civil penalty has been assessed from 4/14/2022 to 4/19/2022 at $100 x 6 = $600. LPAs printed out regulations 87705 for Administrator to review and submit correct documents. Plan and proof of correction was discussed with Administrator. Civil Penalties will continue to be assessed daily until corrected. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.

On 8/13/2021 at 2:55pm, Licensing Program Analyst (LPA) L. Francisco arrived to conduct a Component III presentation. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit. LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the Administrator gained knowledge about running and maintaining the facility in accordance with regulations. Exit interview conducted and a copy of this report provided.