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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201054
Report Date: 06/19/2025
Date Signed: 07/02/2025 08:57:58 AM

Document Has Been Signed on 07/02/2025 08:57 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MORI MANORFACILITY NUMBER:
019201054
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ, FERDINANDFACILITY TYPE:
740
ADDRESS:1476 164TH AVENUETELEPHONE:
(510) 600-3840
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 11DATE:
06/19/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Mariano Alatoree, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 6/19/2025, at 2:45 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk conducted an unannounced Case Management health and safety check. LPAs met with Mariano Alatoree, Administrator and explained the purpose of the visit. The administrator currently holds a certificate (#6066221740) that expires on 9/25/2025.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, and back yard. The facility consists of seven (7) bedrooms and three (3) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for residents is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared residents’ bathroom was measured at 105 degrees Fahrenheit.

LPAs observed the following deficiencies:
  • At 4:04 PM, LPAs observed unlocked medication in a resident room and unlocked medication in facility refrigerator.
  • At 4:03 PM, LPAs observed scissors unlocked in a resident room and cleaning solutions and cleaning disinfectants in an unlocked laundry room.
  • At 4:16 PM, LPAs observed facility did not pay outstanding licensing fees.
  • At 4:17 PM, LPAs observed facility did not provide documents for administrator change.
Continue to LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MORI MANOR
FACILITY NUMBER: 019201054
VISIT DATE: 06/19/2025
NARRATIVE
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Continued from LIC809.

The deficiencies were cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties

Exit interview conduct. A copy of this report, Civil Penalty, and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/02/2025 08:57 AM - It Cannot Be Edited


Created By: Yasamin Brown On 06/19/2025 at 04:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR
FACILITY NUMBER: 019201054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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Administrator removed the scissors and locked them up in a locked closet during the visit. Administrator locked the laundry room containing cleaning disinfectants and cleaners during visit. Deficiency cleared.

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Based on observation, the licensee did not comply with the section cited above by having a pair of scissors unlocked in a residents room and unlocked laundry room which poses an immediate health and safety rights risk to persons in care.
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Type B
06/27/2025
Section Cited
CCR87211(g)

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(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
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The Administrator has agreed to provide the required documentation for the change of administrator on or before the POC date.
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Based on record review, the Licensee did not comply with the section cited above by not providing the documentation required for administrator change which poses a potential personal rights risk to persons in care.
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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 08:57 AM - It Cannot Be Edited


Created By: Yasamin Brown On 06/19/2025 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MORI MANOR
FACILITY NUMBER: 019201054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
87156(a)

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87156 Licensing Fees
(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
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Administrator agreed to make payment and provide proof of that payment to CCL on or before the POC date.

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This requirement is not met as evidenced by:
Based on record review and interview, the licensee did not comply with the section above by not paying the late/licensing fees which poses an immediate health and safety risk to persons in care.
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Type A
06/20/2025
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator has agreed to obtain lock boxes for medications in the refrigerator and resident's room. Administrator will submit picture proof to CCL on or before the POC date.
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Based on observation, the licensee did not comply with the section cited above in having unlocked medications in refridegerator and a resident's room which poses an immediate health and safety risk to persons in care.
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Civil Penalty of $250 is being assessed for repeat violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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