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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:40:27 PM


Document Has Been Signed on 04/19/2022 02:40 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: 9DATE:
04/19/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Ferdinand Gutierrez, AdministratorTIME COMPLETED:
02:50 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
On 4/19/22 approximately 1:50pm, Licensing Program Analysts (LPAs) C. Lin and K. Nguyen arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit.

Administrator admitted that he has not submitted POC for 87705(f)(2). A civil penalty has been assessed from 4/14/2022 to 4/19/2022 at $100 x 6 = $600.

LPAs printed out regulations 87705 for Administrator to review and submit correct documents. Plan and proof of correction was discussed with Administrator.

Civil Penalties will continue to be assessed daily until corrected.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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 1