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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 10/24/2023
Date Signed: 10/24/2023 05:58:08 PM


Document Has Been Signed on 10/24/2023 05:58 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: 9DATE:
10/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Ferdinand Gutierrez/Administrator TIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit and met with Ferdinand Gutierrez, administrator, and informed the reason for visit.

On 9/29/23, LPA Delmundo issued citations for the following deficiencies with POCs to be submitted by 9/30/23; however, administrator submitted the POCs on 10/01/23. Civil penalties of $100.00 each for the following is assessed on this day, 10/24/23:
1. Section # 87705(1) Care of Persons with Dementia
2. Section # 87705(f)(2) Care of Persons with Dementia

Deficiency section # 87458(a) Medical Assessment was also cited on 9/29/23 is being re-cited on this same day for failure to submit POC by 10/13/23:

Deficiency section # 87463(c) Reappraisals - Administrator showed to LPA R2's LIC625 Appraisal/Needs and Services Plan which was completed on 10/09/23; however, administrator failed to submit the POC by 10/13/23. This deficiency is cleared on this day.

Deficiencies and civil penalties were discussed with administrator who authorized staff, Rosamaria Munoz to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form 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: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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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Document Has Been Signed on 10/24/2023 05:58 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: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a)Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
-This requiement is not met as evidenced by:
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Administrator to do the following and submit proof by 11/07/23.
1. Have an appointment schedule with R2's doctor.
2. Obtain an updated LIC602A.
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-Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care. This is a re-citation.
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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: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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