Mori Manor

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.

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.

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.

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.

(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.

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.

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.

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.

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 violation

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 thefacility 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,

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.

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.

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.

87311 TelephonesAll 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 problems

87203 Fire SafetyAll 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.

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.

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,

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.

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.

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,

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.

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.

87303 Maintenance and Operation87303 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.

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.

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,

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,

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.

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.

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.

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from otherresponsibilities and shall be on the ... ...premises a sufficient number of hours to permit adequate attention to the management and administration of the facility.-This requirement is not met as evidenced by:-Administrator failed to demonstrate ....

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2.-This requirement is not met as evidenced by: -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.

87470 Infection Control Requirements(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.-This requirement in not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section above for not having an Infection Control Plan which poses potentiall health risk to persons in care.

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 observation and interview, the licensee did not comply with the section above for R4 who has insulin but no file and/or record of doctor's order. Insulin was not administered and facility does not have discontinued order. It's not clear it the med is still needed.

87411 Personnel Requirements - General; (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.-This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for staff affixing initial on R4's MAR but the medication was not administered.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance ... This requirement is not met as evidenced by:-Based on records review, the licensee did not comply with the section above for S2 who is not associated to this facility.This is a repeat violation within 12 month period. First violation was issued on 7/18/23.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required.... ... by the Department-This requirement is not met as evidenced by:-Based on observation, interview and Guardian Portal check, the licensee did not comply with section above for having S1 work without fingerprint clearance.This is a repeat violation.

§1569.605 Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, .... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate.....-This requirement is not met as evidenced by:-Based on records review and interview, the licensee did not comply with the section for not having insurance coverage under licensee's name.

§1569.69 Employees assisting residents with self-administration of medication; training requirements(b) Each employee who received training and passed the examination... and who continues to assist with the self-administration of medicines, shall also complete four hours.. of in-service training on medication-related issues in each succeeding 12-month period.-This requirement is not met as evidenced by:-Based on records review and interview, the licensee did not comply with the section for S3 not having the required hours of annual medication training,

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. -This requirement is not met as evidenced by:-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,

87705 Care of Persons with Dementia(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, ifexiting 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, for entrance and exit doors not having auditory signals which posed immediate risk to persons in care,

87303 Maintenance and Operation(a) The facility shall be clean, safe, sthe safety and well-being of residents, employees and visitors.anitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety -This requirement is not met as evidenced by:-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,

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 for having the storage in the side yard not locked which poses immediate safety risks to persons in care,

87203 Fire SafetyAll 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 byL -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.

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 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.

General Food Service Requirements -All foods shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.This requirement is not met as evidenced by: Based on observation, there were multiple expired foods in the in the pantry, which poses an immediate health and safety risk to residents in care.

87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate....This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed appraisal/care plan has not been updated due to changing in condition.

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia(2) ...alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed unlocked detergent in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.