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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 08/31/2023
Date Signed: 08/31/2023 05:09:42 PM


Document Has Been Signed on 08/31/2023 05:09 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) 600-3840
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: DATE:
08/31/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jene Snipes/Licensee and
Ferdinand Gutierrez/Administrator 		TIME COMPLETED:
05:10 PM
NARRATIVE
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On this day, August 31, 2023, a Non-compliance Conference was conducted. The existing deficiencies, problem areas in the operation of the facility, civil penalties, repeat violations and failure to submit proof of corrections were discussed.

Present at the meeting were:
1. Regional Manager Isaac Taggart
2. Licensing Program Manager (LPM) Jeremy Fong
3 Licensing Program Analyst (LPA) Alicia Delmundo
4. Jene Snipes/Licensee
5. Ferdinand Gutierrez/Administrator
6. Dr Nandeesh Veerappa

Deficiency is cited from Title 22 California Code of Regulations for administrator qualification.

Additional civil penalty is issued on this day for failure to submit proof of corrections by plan of correction due date for $3M liabity insurance coverage (H&S Code 1569.605). This deficiency was cited on 7/27/23. A POC visit was conducted on 8/11/23 for failure to timely correct and with civil penalty will continue until corrected.
CP = $100.00/day x 20 days (8/12/23 to 8/31/23) = $2,000.00

Deficiency and plan of correction were discussed.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty 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: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/31/2023 05:09 PM - It Cannot Be Edited

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: 019201054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
87405(a)

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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 other
responsibilities and shall be on the ...
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Administrator to take the following training from Department's vendors:
1. Dementia Care - 8 hours
2. Criminal Record - 2 hours
3. Medication Administration - 8 hours
4. Administration including but not limited to hiring practices, record keeeping. staffing
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...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 ....
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and maintenance - 8 hours
Proof to be submiitedby 9/14/23.
Type B
09/14/2023
Section Cited
CCR87405(a)

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CONTINUATION:
ability to comply with the Regulations as evidenced by multiple citations, civil penalties, issues such as physical plant, staffing, training, records keeping and failure to correct timely.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2