Routine inspection·July 6, 2023

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) 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) 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.