<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:55:41 PM


Document Has Been Signed on 05/08/2024 04:55 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: 7DATE:
05/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mariano Alatorre/AdministratorTIME COMPLETED:
04:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
While at the facility conducting a case management visit for the AWOL incidents, Licensing Program Analyst (LPA) observed during inspection and learned the following from interviews:
1. Overgrown weeds about 1 to 2 feet high in the backyard.
2. Bed frame, head board and bed rails in the side yard.
3. No planned activities.

On 9/31/23, a Non-compliance Conference (NCC) was conducted with the licensee and one of the compliance plans was to have the administrator be present in the facility 40 hours per week. On this day, 5/08/24, LPA reviewed the schedule which showed the administrator is at the facility Monday through Friday from 5:00 pm to 8:00 pm and on-call on Saturdays and Sundays. LPA verified, and the administrator confirmed his schedule of work which is less than 40 hours/week.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $250.00 civil penalty is assessed for each of the repeat violation of deficiency section #'s 87405(a) and 87303(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalties were discussed with the administrator. Administrator has to leave and authorized Maura White to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of correction form, LIC421FC, 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: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 3


Document Has Been Signed on 05/08/2024 04:55 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87405(a)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties:(a).....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the
facility as specified in this section....
1
2
3
4
5
6
7
Administrator to devote 40 work hours/week and submit copy of LIC500 Personnel Report by 5/22/24.

A $250.00 civil penalty is assessed.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by: Based on records review, NCC and interview, the licensee did not comply wth the section above in administrator not in the faciity for 40 hours/week which poses a potential health, safety and/or personal rights risks to persons in care. This is repeat violation,
8
9
10
11
12
13
14
Type B
05/22/2024
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
1
2
3
4
5
6
7
Administrator to have the yards cleaned and submit pictures by 5/22/24.

A $250.00 civil penalty is assessed.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply wth the section above in overgrown weeds in the backyard, and bed frame, head board and bed rails in the side yard which pose a potential safety risks to persons in care. Ths is a repeat violation
8
9
10
11
12
13
14
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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/08/2024 04:55 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87219(d)

1
2
3
4
5
6
7
87219 Planned Activities
(d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies...........
1
2
3
4
5
6
7
Administrator to do the following, and submit proof by 5/22/24:
1. Come up with resident appropriate activities schedule.
2. Ensure that the planned activities are conducted.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by:

-Based on observation and interviews, the licensee did not comply with the section above for not having planned activites for residents.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3