Mori Manor

Type of visit: Annual/Random

On 8/31/2026 at 10:00 am, Licensing Program Analyst (LPA) Y. Brown arrived to conduct an unannounced annual 1-year required inspection. LPA met with care staff Edna Yee and explained the purpose of the visit. Edna phoned Administrator (AD) Mariano Alatorre who arrived to the facility around 10:15 am. The administrator currently holds a certificate (#7032373740) that expires on 9/25/2027. 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 residents is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the facilities shared resident restroom was measured at 108.6 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 serviced on 04/23/2026. First aid kit was observed to be complete. LPA reviewed five (5) staff and six (6) resident records. Emergency disaster plan was last reviewed on 6/01/2026. LPA reviewed a sample of medication. Continued on LIC809C. Continued from LIC809. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/7/2026: LIC610D: Emergency disaster plan LIC500: Personnel Record Liability Insurance The following deficiency was observed: At 11:30 am, LPA observed that the facility is pre-pouring resident medication. 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 with Mariano. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Sep 9, 2026

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section above in pre-pouring residents' medications which poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: By POC date, the Administrator agrees to stop pre-pouring the medications, conduct an in-service training and send a self-certification to be submitted to CCLD.

Allegation investigated: Staff at the facility are not monitoring resident's blood pressure

On 2/3/2026 at 9:45 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Care staff Maria Manjarez. During the complaint visit, LPA reviewed the LIC 500 (Personnel report) and LIC9020 (client roster), interviewed the RP, S1, R1, and reviewed R1's record. Continue to LIC9099-C. Unsubstantiated 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.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 15-AS-20260128135521

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 4, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not as evidence by: 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.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: By POC date, the Administrator agrees to submit proof of R1's medication obtained to CCLD.

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Case Management - Deficiencies

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 summary 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.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Sep 4, 2025

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to [...] This requirement is not met as evidenced by: Based on record review and interview the Licensee did not comply with the section cited above by not calling 9-1-1 when R1 was complaining of pain which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: The Administrator has agreed to review regulation and self certify with signatures by POC date.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Incident

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. 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.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Case Management - Health Checks

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. 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.the state’s words, verbatim · CDSS document, Jun 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jun 20, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Administrator removed the scissors and locked them up in a locked closet during the visit. Administrator locked the laundry room containing cleaning disinfectants and cleaners during visit. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(g) · Plan of correction due date: Jun 27, 2025

(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: 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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: The Administrator has agreed to provide the required documentation for the change of administrator on or before the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87156(a) · Plan of correction due date: Jun 20, 2025

87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Administrator agreed to make payment and provide proof of that payment to CCL on or before the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jun 20, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Administrator has agreed to obtain lock boxes for medications in the refrigerator and resident's room. Administrator will submit picture proof to CCL on or before the POC date. Civil Penalty of $250 is being assessed for repeat violation.

Allegation investigated: Staff physically abused resident

On 05/15/2025 at 12:10 PM, Licensing Program Analysts (LPA), J. Clancy-Czuleger arrived unannounced to deliver complaint findings for the above allegations. LPA met with Marian Alatorre, Administrator and explained the reason for the visit. During the course of the investigation, LPA obtained information, reviewed records, collected documents and interviewed staff and residents. It was alleged that a staff member physically abused resident by punching R1 in the arms and shoulders. However, based on interview staff denied hitting or pushing R1 nor observed other staff hitting or pushing other R1 or other residents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 15, 2025 · control 15-AS-20250205154358

Type of visit: Required - 1 Year

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... 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)the state’s words, verbatim · CDSS document, Sep 11, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 22, 2024

87405 Administrator - Qualifications and Duties:(a).....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.... -This requirement is not met as evidenced by: Based on records review, NCC and interview, the licensee did not comply wth the section above in administrator not in the faciity for 40 hours/week which poses a potential health, safety and/or personal rights risks to persons in care. This is repeat violation,the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Administrator to devote 40 work hours/week and submit copy of LIC500 Personnel Report by 5/22/24. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: May 22, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply wth the section above in overgrown weeds in the backyard, and bed frame, head board and bed rails in the side yard which pose a potential safety risks to persons in care. Ths is a repeat violationthe state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Administrator to have the yards cleaned and submit pictures by 5/22/24. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(d) · Plan of correction due date: May 22, 2024

87219 Planned Activities (d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies........... -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above for not having planned activites for residents.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Administrator to do the following, and submit proof by 5/22/24: 1. Come up with resident appropriate activities schedule. 2. Ensure that the planned activities are conducted.

Type of visit: Case Management - Incident

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) 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.the state’s words, verbatim · CDSS document, May 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: May 9, 2024

87705 (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by -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.the state’s words, verbatim · CDSS document, May 8, 2024

Plan of correction: Auditory signals were turned on while LPA was at the facility. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/09/24.

Allegation investigated: Facility is not storing an adequate amount of food for residents in care.

On 4/30/2024 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with staff. Administrator Mariano Alatorre was called and joined later. During the initial 10-day complaint visit, LPA observed the facility did not have sufficient food supply. The freezer in the kitchen and the freezer in the laundry were both half empty. The additional food supply is locked in a storage closet and when it was opened it was observed half stocked. LPA observed the kitchen pantry was not well stocked. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 30, 2024 · control 15-AS-20240422150459

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: May 14, 2024

Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Apr 30, 2024

Plan of correction: Administrator agreed to purchase food and submit photos of food and receipts to CCLD by POC date.

Allegation investigated: Facility telephone is in disrepair

On 11/07/2023 at 10:30 AM Licensing Program Analysts (LPA) P. Watson arrived unannounced to conduct a complaint investigation for the above allegation. LPA met with Administrator, Ferdinand Gutierrez, and explained the purpose of the visit. During the course of the investigation, LPA toured facility and interviewed staff. It was alleged that Facility telephone is in disrepair, based on interview with Administrator the facilities telephone was in disrepair for about 5 (five) days and was recently fixed. Administrator stated that they believe there were internet problems causing the phones to be in disrepair. Some of the residents have personal cell phones and were able to communicate with family members while the facility telephone was not operable, for the resident who does not have a personal cell phone their family members were unable to speak to them unless they called the Administrator and/or owner. Report continues on 9099 C Substantiated 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.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 15-AS-20231031165312

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Nov 10, 2023

87311 Telephones All facilities shall have telephone service on the premises... This requirement is not met as evidence by: 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 problemsthe state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Deficiency cleared during visit, Administrator stated that the facility telephone was repaired about 3 (three) days ago and is operable. LPA called the facility telephone and confirmed it is working.

Type of visit: Case Management - Other

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) 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.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 25, 2023

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for smoke detectors in R1's room removed which poses immediate safety risk to person in care. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 10/25/23. A $1,000.00 civil penalty is assessed today.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 25, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications..(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. -This requirement is not met as evidenced by: -Based on observation. the licensee did not comply with the section above for medications unlocked in R1's room which poses immediate health and/or personal rights risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff took and locked the medications. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 25, 2023

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for unlocked storage, shovel in the side yard, weed killer in cabinet without lock in the foyer, wound cleanser in cabinets without lock, and scissors. These pose immediate health and safety risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff put shovel and weed killer in the storage and lock the storage, In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 7, 2023

87303 Maintenance and Operation 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for mouse droppings and protruding drain pipe which pose potential safety risks to persons in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator called Pest Control company to provide service. Proof of service to be submitted by 11/07/23. In addition, administrator to do the following and submit proof by 11/07/23: 1. Have the mouse droppings cleaned-up and submit picture. 2. Have the protruding pipe fixed and submit picture. A $250.00 civil penalty is assessed,

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Nov 7, 2023

87608 Postural Supports (a) ....Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record....... -This requirememt is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's half bed rails without doctor's order on file which poses potential personal rights risk to person in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to obtain doctor's order and submit copy by 11/07/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 7, 2023

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC9172 and Appraisal indicated ambulary, which are not consistent with LIC602A which showed bedridden. These pose potential safety and/or personal rights risks to person in care. This is a repeat violation.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to have R2 seen by primary care physician (pcp) and update the documents accordingly. Copies of updated Appraisal and LIC9172 to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(5) · Plan of correction due date: Nov 7, 2023

87458 Medical Assessment (b) The medical assessment shall include, .. (5) The determination whether the person is ambulatory or nonambulatory ... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. -Based on record review, the licensee did not comply with the section above for R2's LIC602A indicated bedridden which poses potential safety and/or personal rights risks to persons in care. This is a repeat violation,the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to have R2 seen by pcp and have the LIC602A updated and copy to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(24) · Plan of correction due date: Nov 7, 2023

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for keeping the weed killer in the cabinet where food supplies are kept which poses potential health and/or personal right rsks to persons in care,the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Staff removed and locked the weed killer. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/07/23.

Type of visit: POC

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, administrator 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.the state’s words, verbatim · CDSS document, Oct 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Nov 7, 2023

87458 Medical Assessment (a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. -This requiement is not met as evidenced by: -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.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator to do the following and submit proof by 11/07/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

Type of visit: Case Management - Other

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 -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.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(1) · Plan of correction due date: Sep 30, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). -This requirement is not met as evidenced by: -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,the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: LPA had the items locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Sep 30, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to.....(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. -This requirement is not met as evidenced by: -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,the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: LPA had the item locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Sep 30, 2023

87465 Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file..... -This requirement is not met as evidenced by: -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.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to obtain doctor's order and submit copy by 9/30/23. A $250.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(e) · Plan of correction due date: Sep 29, 2023

CONTINUATION OF THE ABOVE: This is a repeat violation within 12 months. First citation was issued on 7/27/23.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed......... (4) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by: -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.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to obtain the medications and submit pictures by 9/29/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Oct 13, 2023

87458 Medical Assessment (a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. -This requiement is not met as evidenced by: -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.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to do the following and submit proof by 10/13/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(e) · Plan of correction due date: Oct 13, 2023

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative,,,, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467...... -This requirement is not met as evidenced by: -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.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator to have the appraisal updated and submit copy by 10/13/23.