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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 07/18/2023
Date Signed: 07/18/2023 08:24:14 PM


Document Has Been Signed on 07/18/2023 08:24 PM - It Cannot Be Edited

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: 12DATE:
07/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
07:40 PM
MET WITH:Ferdinand Gutierrez/AdministratorTIME COMPLETED:
08:15 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit, and met with Ferdinand Gutierrez, administrator. LPA informed the reason for visit.

On July 6, 2023, LPAs Delmundo and Fontanilla started the annual required inspection. Deficiency section 87204(a) was cited for having 2 non-ambulatory residents in ambulatory only rooms. Administrator stated he'll have the residents moved to rooms with fire clearance for non-ambulatory with proof of correction (POC) to be submitted by July 7, 2023. A civil penalty was assessed on July 6, 2023 which will continue until corrected.

As of this day, July 18. 2023, administrator has not submitted the POC, LPA Delmundo conducted inspection and interviewed staff (S1) and administrator who both stated that resident (R3) was only moved on Tuesday, July 11, 2023.



An additional civil penalty of $400.00 is assessed on this day for $100.00/day from July 8, 2023 to July 11, 2023 and was discussed with the administrator. Administrator has to leave, and authorized JulyFrancia Yambao, staff, to sign and received this report.

Copy of this report, Appeal Rights and LIC421FC Civil Penalty Assessment provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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