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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:15:47 AM


Document Has Been Signed on 04/28/2022 10:15 AM - 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: 11DATE:
04/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Gladys Salguero, CaregiverTIME COMPLETED:
10:30 AM
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On 4/28/22 approximately 9:25am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 4/14/2022. LPAs met with caregiver Gladys Salguero and spoke with Administrator, Ferdinand Gutierrez on the phone, and explained the purpose of the visit.

Administrator had submitted resident's Needs & Service Plan to CCL via email at 3:24pm on 4/22/22, however had LPA's email in error so LPA didn't received it. Administrator resubmitted it to LPA during visit. LPA obtained resident's note of changing in condition during visit. Administrator forgot to retrain staff for regulation, and admitted that the training would be provided and submitted to CCL today, 4/28/22, otherwise civil penalty will be issued.

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: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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