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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:10:05 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:
019201054
ADMINISTRATOR:GUTIERREZ, FERDINANDFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 276-6167
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 11DATE:
06/17/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Ferdinand Gutierrez, AdministratorTIME COMPLETED:
03:20 PM
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On 6/17/2021 starting at 12:25pm, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a Pre-licensing visit. Upon arrival, LPA met with care staff, Gladys Salguero and contacted Licensee, Jene Snypes over the phone to explain the purpose of the visit. Administrator, Ferdinand Gutierrez later arrived at 1:05pm.

LPA toured facility including but not limited to the resident bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. There is sufficient lighting throughout the facility. Residents rooms are equipped with the proper furniture and lighting. Resident rooms have proper bedding and linens for the resident's to use. The kitchen was observed cleaned and within compliance. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects are locked. Passageways and hallways are free of obstruction. Fire extinguisher is in was observed fully charged. Smoke detectors and Carbon Monoxide detector are equipped around the facility. Medication cabinet has a lock and first aid kit is complete. This is an existing facility and 2-day perishable and 7-day nonperishable are available for the clients.

Upon arrival, LPA observed a for sale sign at the front yard of the facility. LPA inquired about the property over the phone with Licensee, and it was revealed that the facility is currently listed on the market.

LPA will not be recommending for facility to be licensed at this time until issue has been resolved. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. Once issue is resolved, LPA will return to facility and complete COMP III.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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