Mori Manor.
Mori Manor is Ranked in the bottom 7% on repeat-citation rate among California peers with 47 CDSS citations on record; last inspected Feb 2026.
Small Memory Care Home in San Leandro's Residential East Side, reviewed on public record.
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Compared to 152 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Mori Manor has 47 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
47 deficiencies on record. Each bar is a month with a citation.
Finding distribution
47 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Mori Manor's record and state requirements.
State records show 5 Type A deficiencies (actual harm citations) — what were the specific circumstances of each, and what corrective actions were implemented?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Eight complaints have been filed with CDSS — how many were substantiated, what were the subjects, and what changes resulted from the investigations?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
With 17 Type B deficiencies (potential for harm) across 36 inspection reports, what systemic changes has the facility made to reduce recurring compliance issues?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
25 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-02-03Other VisitType A · 1 finding
Plain-language summary
During an unannounced visit on February 3, 2026, inspectors found that the facility did not obtain medication refills for a resident in a timely manner. The facility was cited for this violation and notified that failure to correct it could result in penalties. An exit interview was conducted with staff and the facility received a copy of the report and information about appeal rights.
“Based on record review and interview, the licensee did not comply with the section above by not obtaining medication refills in a timely manner for R1 which poses an immediate health and personal rights risks the persons in care.”
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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.
2025-09-30Annual Compliance VisitNo findings
Plain-language summary
On September 30, 2025, inspectors conducted an unannounced follow-up visit to check on the facility's conditional use permit renewal process. The inspector toured the facility, met with the administrator, and found no deficiencies. The facility will continue working with the licensing program on the permit renewal.
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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.
2025-08-28Other VisitNo findings
Plain-language summary
On August 28, 2025, state inspectors conducted a routine annual inspection of the facility and found no violations. The inspector toured all areas including bedrooms, bathrooms, kitchen, and outdoor spaces, and reviewed resident and staff records, confirming that safety equipment, sanitation, lighting, temperature control, and medications were all in proper working order.
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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.
2025-07-15Other VisitNo findings
Plain-language summary
On July 15, 2025, regulators conducted an unannounced follow-up inspection after receiving an incident report about a resident with a history of falls. The resident complained of leg pain on July 2nd and was transported to the hospital on July 3rd, where a small fracture in the lower leg bone was found; the facility believes the fracture may have occurred during a transfer using a lift. The facility is updating the resident's care plan with new fall prevention strategies.
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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.
2025-06-19Other VisitType A · 4 findings
Plain-language summary
During an unannounced health and safety check on June 19, 2025, inspectors found that medications were left unlocked in a resident room and in the facility refrigerator, scissors were unlocked in a resident room, and cleaning solutions were unlocked in the laundry room. The facility also had not paid outstanding licensing fees and did not provide required documents for an administrator change. The facility was given a deadline to submit corrections and warned that failure to do so could result in civil penalties.
“Based on observation, the licensee did not comply with the section cited above in having unlocked medications in refridegerator and a resident's room which poses an immediate health and safety risk to persons in care.”
“Based on observation, the licensee did not comply with the section cited above by having a pair of scissors unlocked in a residents room and unlocked laundry room which poses an immediate health and safety rights risk to persons in care.”
“Based on record review, the Licensee did not comply with the section cited above by not providing the documentation required for administrator change which poses a potential personal rights risk to persons in care.”
“Based on record review and interview, the licensee did not comply with the section above by not paying the late/licensing fees which poses an immediate health and safety risk to persons in care.”
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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.
2025-06-19Annual Compliance VisitNo findings
Plain-language summary
On June 19, 2025, inspectors conducted a routine follow-up visit to check on the facility's progress toward obtaining a conditional use permit from Code Enforcement. The administrator confirmed that the new applicant/licensee is working with Code Enforcement to complete required corrections. No violations were found during this visit.
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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.
2025-05-15Complaint InvestigationUnsubstantiatedNo findings
2024-09-11Other VisitType A · 2 findings
Plain-language summary
During an unannounced annual infection control inspection on September 11, 2024, inspectors found that medication was left unlocked on a kitchen table and that window screens were missing from kitchen, bedroom, and common areas. The facility addressed the unlocked medication during the visit, and inspectors noted adequate food supplies, functional safety equipment, and proper infection control signage throughout the facility.
“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.”
“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.”
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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... 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)
2024-05-08Other VisitIJ · 1 finding
Plain-language summary
On May 8, 2024, a state licensing analyst investigated two incidents in which a resident left the facility without staff supervision on April 21 and May 3, 2024; the resident was located by police both times and returned safely without injury. The investigator found that auditory alarm signals on doors leading outside had been turned off, which violated state regulations designed to protect residents who may leave unassisted. The facility was cited for this violation and assessed a $250 civil penalty, with daily fines continuing until the doors are properly alarmed.
“-Based of observation, the licensee did not comply with the section above in entrance/exit doors auditory signals turned off which posed immediate risk to persons in care, This is a repeat violation within 12 month period. First citation was issued on 6/28/23.”
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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.
2024-04-30Complaint InvestigationSubstantiatedType B · 1 finding
“Based on observation, the facility did not have sufficient supply of non perishable foods which poses a potential risk to health and safety of clients under care.”
2023-11-07Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
A complaint investigation found a violation of California care facility regulations. The facility was cited for the violation and provided with information about appeal rights. The specific details of what was found are not included in this summary.
“Based on interview the licensee did not have telephone service for the residents which poses/posed a potential Health, Safety or Personal Rights risk to persons in care. Administrator stated that the phone was in disrepair for about 5 (five) days due to internet problems”
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Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. Exit interview conducted. A copy of this report and appeal rights provided .
2023-10-24Other VisitType B · 1 finding
Plain-language summary
A state inspector conducted an unannounced follow-up visit on October 24, 2023, to verify that the facility had corrected previous violations related to dementia care and medical assessments. The facility was assessed civil penalties of $100 each for late submission of correction documentation and for failing to timely complete a resident's care plan reassessment, though the reassessment was eventually completed and the violation was cleared during this visit. The administrator was informed of appeal rights and provided copies of the inspection report.
“-Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care. This is a re-citation.”
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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.
2023-09-29Other VisitType A · 7 findings
Plain-language summary
This was a follow-up inspection on September 29, 2023 to check on corrections from a previous non-compliance conference. The inspector found multiple issues: hazardous materials (weed killer, shaving cream, shovel) left unsecured in common areas; one resident had eight medications prescribed but no doctor's orders on file; another resident's medications on hand did not match the prescribed list, with some having wrong dosages and others missing entirely; and required medical documentation and care planning were outdated or incomplete, including a missed follow-up appointment that the facility had not scheduled.
“-Based on observation, the licensee did not comply with the section above for having shovel and shave cream unlocked which poses an immediate safety risks to persons in care,”
“-Based on observation, the licensee did not comply with the section above for weed and grass killer unlocked which poses an immediate risk to persons in care,”
“-Based on records review, the licensee did not comply with the section above for not having doctor's order for R1's 8 medications which poses immediate health risk To person in care.”
“CONTINUATION OF THE ABOVE: This is a repeat violation within 12 months. First citation was issued on 7/27/23.”
“-Based on records review, the licensee did not comply with the section above for not having 3 of R2's medications and 2 medications dosage and stregth different from the order which poses immediate risks to person in care.”
“-Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care.”
“-Based on record review, the licensee did not comply with the section above for R2's LIC625 Appraisal/Needs and Services Plan more than a year old which poses potential health and/or personal rights risks to person in care.”
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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.
2023-08-31Other VisitType B · 2 findings
Plain-language summary
On August 31, 2023, the facility held a compliance conference to address ongoing problems, including a deficiency related to administrator qualifications and failure to provide proof of adequate liability insurance coverage by the required deadline. The facility was assessed a civil penalty of $2,000 for the delay in correcting the insurance issue between August 12 and August 31, 2023. The facility was notified of its appeal rights and provided with copies of the findings.
“-Administrator failed to demonstrate ....”
“CONTINUATION: ability to comply with the Regulations as evidenced by multiple citations, civil penalties, issues such as physical plant, staffing, training, records keeping and failure to correct timely.”
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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.
2023-08-11Other VisitNo findings
Plain-language summary
A follow-up inspection on August 11, 2023 found the facility had not corrected multiple deficiencies from a prior citation, including lack of working call buttons, incomplete staff training, inadequate bathroom supplies, missing resident files, and unsubmitted proof of liability insurance and disaster drill documentation. The state assessed civil penalties totaling $6,900 for late or incomplete corrections, with additional daily penalties continuing until the facility submits proof that these issues have been fixed. The administrator was given corrected paperwork requirements and informed of appeal rights on the day of the inspection.
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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.
2023-07-27Other VisitNo findings
Plain-language summary
On July 27, 2023, inspectors conducted a follow-up visit to verify corrections to violations found during a previous inspection and discovered that the facility had submitted required corrective actions late, resulting in $1,200 in civil penalties for delays in addressing staffing and policy documentation issues. The facility has since posted the required theft and loss policy, and the violations have been corrected.
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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.
2023-07-27Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A complaint investigation found that staff failed to adequately supervise a resident who went missing and was located by police, and that the facility had no records on file for this resident despite having them in care. The facility was cited for these violations and required to submit a correction plan by the deadline or face civil penalties. Staff interviewed confirmed they had no documentation for the resident and could not provide information to law enforcement when they responded to the facility.
“-Based on interviews and review of police reports, the licensee did not comply with the section above for R1 who was able to AWOL which posed immediate safety risk to person in care.”
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Staff filed missing person report to local law enforcement. Police reports confirmed R1 AWOLed on the said dates. Based on information gathered, the preponderance of evidence has been met, therefore the allegation of 'staff did not adequately supervise resident (R1) while in care' is closed as substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Allegation: Staff do not maintain records regarding resident (R1) in care. It was alleged that when law enforcement responded and went to the facility, the staff were not able to provide information for R1. All staff interviewed stated R1 does not have record at the facility. During the 10-day initial visit on June 28, 2023, LPA asked the administrator for R1's file and administrator stated R1 has no record. Based on information obtained, the preponderance of evidence has been met, therefore the allegation of 'staff do not maintain records regarding resident (R1) in care' is substantiated. Deficiency section 87506(a) was cited during annual inspection on July 18, 2023 with proof of correction to be submitted by 8/01/23. Deficiencies, plan and proof of corrections were discussed with the administrator. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2023-07-18Other VisitType A · 18 findings
Plain-language summary
During a continuation of the annual inspection in July 2023, inspectors found multiple safety and operational issues, including broken window blinds and exposed wires in bedrooms, debris scattered in outdoor areas, expired staff certifications (First Aid and CPR), insufficient staffing to safely transfer residents who need two-person assistance, missing resident medical records and tuberculosis test documentation, and several staff members who lacked required annual training or were not properly associated with the facility. Inspectors also found that a staff member administered medications without the required training (last trained in 2016) and that the facility did not maintain fire drill records despite staff stating they do not conduct fire drills. The facility was assessed civil penalties totaling $750 for these violations.
“Based on observation, the licensee did not comply with the section cited above for not having LIC9020 Register of Facility Clients/Residents which poses/posed a potential health,or personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to complete a LIC9020 and submit copy by 8/01/23.”
“Based on observation, the licensee did not comply with the section cited above for not posting facility's Theft and Loss Policy which poses a potential personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to post the policy, and submit picture by 8/01/23.”
“Based on observation, the licensee did not comply with the section cited above for the following: (a) pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard; (b) mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard; (c) broken window blinds and protruding cable wires in room # 2. These pose a potential safety and/or personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator had the yards clean. Administrator to have the window blinds replaced with new one and removed the protruding cable. Pictures to be submiited by 8/01/23, A $250.00 civil penalty is assessed for repeat violation. First citation was issued on 6/28/23.”
“Based on observation, the licensee did not comply with the section cited above for resident not having signal system or call button which pose a potential health, safety and/orr personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to purchase call button, and submit by 8/01/23 proof of purchase and pictures.”
“Based on observation, licensee did not comply with the section cited above for not posting Complaint poster which poses a potential personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to post the poster in the prominent place and submit picture by 8/01/23.”
“Based on interview and record review, the licensee did not comply with the section cited above for S1 not fingerprint cleared which poses an immediate safety and/or personal rights risk to persons in care. POC Due Date: 07/20/2023 Plan of Correction 1 2 3 4 Administrator to have S1 fingerprinted and associated. In addition, administrator not to allow S1 to work until cleared and associated. Proof to be submitted by 7/20/23. A $500.00 civil penalty is assessed.”
“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 the insulin in the refrigerator which poses an immediate health and safety risks to persons in care. POC Due Date: 07/19/2023 Plan of Correction 1 2 3 4 Staff locked the item. In addition, administrator to in-service the staff, and submit copy of training topic with attendees signatures by 7/19/23.”
“Based on record review, licensee did not comply with the section cited above for 1 staff with no CPR/First and 4 staff with expired CPR/First Aid certiicates on file which posed a potential safety and/or personal rights risks to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Corrected. Staff completed the training.”
“Based on record review, the licensee did not comply with the section cited above for staff (S6) not associated to this facility which poses a potential personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to have the staff associated and submot proof by 8/01/23.”
“Based on interview and reord review, the licensee did not comply with the section cited above for not conducting disaster driill which poses a potential safety risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to conduct drills, and submit proof by 8/01/23.”
“Based on observation and interview, the licensee did not comply with the section cited above for having cameras installed that capture audio which poses a potential personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Corrected. Administrator removed all the camera.”
“Based on interview and rord review, the licensee did not comply with the section cited above for R4 and R6 not having records which pose a potential health, safety and/or personal rights risks to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to complete the records, and submit self-certification by 8/01/23 stating records were completed.”
“Based on interview and record review, the licensee did not comply with the section cited above for not having doctor's order for R2's half bed rails which poses a potential safety and/or personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to obtain doctor's order, and submit copy by 8/01/23.”
“Based on record review, the licensee did not comply with the section cited above for R5 not having TB test on file which poses a potential health risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to schedule an appointment, and submit copy of test by 8/01/23.”
“Based on observation, interviews and record review, the licensee did not comply with the section for R7 who is non-ambulatory but LIC602A Physician's Report indicated ambulatory which poses a potential health and safety riisks to person in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator stated he'll have the LIC602 Physician's Report updated. Copy to be submitted by 8/01/23.”
“Based on interview and record review, the licensee did not comply with the section cited above for 4 staff not having the required annual training which poses a potential health, safety and/or personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to have the staff complete the training and submit proof by 8//01/23.”
“Based on observation and interview and review of staff schedule, the licensee did not comply with the section cited above for not having sufficient staff which poses a potential health, safety and/or rsonal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator stated he'll have the staffing increased. Copy of staff schedule to be submitted by 8/01/23.”
“Based on observation, the licensee did not comply with the section cited above for not having paper towels for residents use for drying hands in 2 bathrooms which pose a potential health and/or personal rights risk to persons in care. POC Due Date: 08/01/2023 Plan of Correction 1 2 3 4 Administrator to provide paper towels in paper towel holders. Pictures to be submiitted by 8/01/23.”
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on July 6, 2023. LPA was granted entry by Maria Manjare, staff. Ferdinand Gutierrez, administrator, arrived after several minutes. LPA informed the reason for visit. LPA also met with other staff, JulyFrancia Yambao. On July 6, 2023, LPAs Delmundo and Fontanilla observed the following but LPAs were not able to issue citations due to technical difficulties/issues: -facility's Theft and Loss policy not posted and no Complaint poster. -broken window blinds and protruding cable wires in room # 2. -no paper towel in dispensers in 2 bathrooms. According to staff, supply of paper towel for the type of dispensers ran out - at 12:02 pm, CALRes incontinence since and Pine Sol cleaning agent in the bathrooms. -pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard. -mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard. --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. - 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. ......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 -On 7/06/23, LPA Fontanilla observed staff (S1) does not have First Aid/CPR training on file. S4 and administrator's First Aid/CPR certificates expired. -LPAs Delmundo and Fontanilla observed cameras in the living room. kitchen and family room. LPAs checked with staff who has access to the camera and observed the cameras also capture audio. The following additional deficiencies were also observed: -S1, S2, S3 and S4 do not have the 20 hours required annual training. -S3 administers medications but does not have required 8 hours annual training. Last training on file was dated 2016. -Staff (S6) who came to work at 5:00 pm 7/06/23 and on this day (7/18/23) not associated to this facility. -Resident's (R2) bed has half bed rails but no doctor's order on file. -Resident (R6) also does not have records. -Resident (R5) has no TB test record on file. -Residents do not have call buttons. -Three residents need 2 person assist in transferring which LPA confirmed with 2 staff and administrator; however, there are only 2 staff scheduled at the time leaving other residents with no staff available to assist. -Resident's (R7) LIC602A PhysIcian's Report indicated ambulatory; however, R7 needs assistance in transferring which LPA confirmed with the staff, administrator and family member. -No LIC9020 Register of Facility Clients/Residents Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500 civil penalty is assessed for section 87355(e)(1), .and $250.00 for repeat violation of section 87303(a) within 12 month period. Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Administrator has to leave and authorized JulyFrancia Yambao to sign and receive this report. Copy of this report, Appeal Rights, LIC9098 Proof of Correction form, LIC421IM and IC421FC Civil Penalty Assessments provided.
2023-07-17Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation looked into allegations that staff left residents in bed too long, failed to secure medications and cleaning supplies, and did not maintain safe common areas. The investigator found no evidence to support these complaints—residents reported getting up daily for meals and activities, staff confirmed residents are taken out of bed regularly, and the investigator observed cleaning supplies locked and common areas free of hazards. The facility was issued no violations.
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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.
2023-07-13Annual Compliance VisitNo findings
Plain-language summary
An informal conference was held on July 13, 2023, to discuss non-compliance issues at the facility, including loss of control of the property and ongoing facility concerns. The state informed the licensee that they remain fully responsible for resident care and supervision while a conditional use permit application is being prepared and submitted to the Department.
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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.
2023-07-06Other VisitType A · 2 findings
Plain-language summary
During a routine annual inspection on July 7, 2023, inspectors found multiple safety and compliance issues, including broken window blinds and exposed wires in a bedroom, paper towel dispensers left empty in two bathrooms, debris scattered in the yard and backyard (including pieces of glass and wood), residents who use mobility aids housed in rooms not designated as safe for non-ambulatory residents, two staff members with expired first aid certifications from 2018 and 2021, no fire drill records on file, and missing required documentation including an infection control plan and emergency disaster plan. The facility also had a staff member not properly fingerprint-cleared, stored medications in a refrigerator without clear administration records for recent months, and the licensee failed to notify regulators when the property was sold. The facility was given until July 20, 2023 to submit corrected documents and face civil penalties of $500 and $250.
“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.”
“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.”
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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) 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) 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.
2023-06-28Other VisitIJ · 4 findings
Plain-language summary
During an inspection related to two complaints, inspectors found that auditory alarm signals on exit doors and some resident room doors were not working, which allowed one resident to leave the facility unnoticed; the facility also had a strong urine smell in common areas, unused mattresses and carpet pieces in the yard, and gardening tools stored unlocked where residents could access them. The administrator was informed of these violations and given a deadline to correct them. The facility's failure to make these corrections by the required date could result in additional penalties.
“-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,”
“-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,”
“-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,”
“-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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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.
2023-06-28Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A complaint investigation found a fire safety violation at the facility. The state assessed a $500 immediate penalty and will charge $100 per day until the problem is fixed. The administrator was notified and given information about how to appeal or submit proof that the violation has been corrected.
“-Based on observation and interview, the licensee did not comply with the section above for removing the smoke detectors in 5 residents rooms and family room. Civil penalty is assessed.”
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Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 immediate civil penalty is assessed for fire safety violation and will continue for $100/day until corrected . Deficiency, plan and proof of correction, and civil penalty were discussed with administrator. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
2023-06-15Other VisitType B · 1 finding
Plain-language summary
During a visit to the facility on June 15, 2023, inspectors found that a resident's required medical and admission documents were not available at the facility for review. The facility stated that these documents were given to paramedics when the resident called 911 in April 2023 and were not recovered from the hospital afterward. The facility was cited for failing to maintain these required records on site.
“This requirement was not met as evidenced by missing resident’s written records at the facility which posed a potential health & safety risk to resident in care.”
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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.
2023-06-15Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
This was a complaint investigation into four allegations about a resident's care, including feeding, water provision, repositioning, and hygiene. All four allegations were found to be unsubstantiated; staff confirmed they offer food, water, repositioning, and hygiene care daily, though the resident frequently refuses these services and also refuses medications, which has resulted in hospitalizations for constipation and bowel impaction. The resident's family member was interviewed and provided a copy of the investigation report.
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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.
5 older inspections from 2021 are not shown in the free view.
5 older inspections from 2021 are not shown in the free view.
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