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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601402
Report Date: 08/09/2021
Date Signed: 08/09/2021 01:17:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MORI MANORFACILITY NUMBER:
015601402
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 9DATE:
08/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Ferdinand Gutierrez, AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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On 8/9/2021 at 11:35 AM Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct a Case Management. LPAs met with Ferdinand Gutierrez, Administrator.

When LPA L. Hall delivered complaint findings (15-AS-20200428133851) on 8/9/2021, two (2) staff were observed not associated to the facility. LPAs was informed that both staff have been working at the facility.

During Investigation Bureau's (IB) investigation. The following was observed:

- On 5/11/2020, one (1) of the bathrooms was out-of-order.
- On 5/11/2020 and 7/8/2020, the closet door in bedroom #5 was broken and leaning.

The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR
FACILITY NUMBER: 015601402
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2021
Section Cited

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Criminal Record Clearance (e)All individuals subject to a criminal record review... prior to working... in a licensed facility:
(1)Obtain a California clearance or a criminal record exemption... This requirement was not met as evidence by:
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Based on observation and record review, Licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care.
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Type B
08/16/2021
Section Cited

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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by:
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Based on observation Licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2021
LIC809 (FAS) - (06/04)
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