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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 07/27/2023
Date Signed: 07/27/2023 06:56:07 PM


Document Has Been Signed on 07/27/2023 06:56 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:
07/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH: Ferdinand Ferdie' Gutierrez/AdministratorTIME COMPLETED:
05:30 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 purpose of visit.

On 7/06/23, LPAs Delmundo and Fontanilla initiated an annual required inspection and issued citation for deficiency section 87309(a) with POC to be submitted by 7/07/23. Administrator submitted the POC only 7/11/23. A $400.00 civil penalty is assessed on this day, 7/27/23, for $100.00/day from 7/08/223 to 7/11/23.

On 7/18/23, LPA Delmundo issued citation for deficiency section 87355(e)(1) for staff who was not fingerprinted with POC to be submitted by 7/19/23. Administrator submitted the POC only on this day, July 27, 2023. A $800.00 civil penalty is assessed for $100.00/day from 7/20/23 to 7/27/23.

Deficiency section 1569.153(a) was cited for Theft and Loss Policy not posted with POC to be submitted by 8/01/23. On this day, LPA observed the Policy is posted.

Exit interview conducted. Appeal Right, LIC421FCs Civil Penalties and copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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