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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200867
Report Date: 11/03/2021
Date Signed: 11/03/2021 06:04:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2019 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20191203145110
FACILITY NAME:GERRYLAIDE MANORFACILITY NUMBER:
019200867
ADMINISTRATOR:CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:261 MEDFORD AVETELEPHONE:
(510) 278-9766
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:32CENSUS: 20DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Aidan Castrence/AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Neglect in seeking medical attention resulted in serious injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings to the allegation. LPA met with Aidan Castrence, administrator, and informed the purpose of visit.

During the course of investigation, LPA obtained copies of C1’s following documents: LIC601 identification and Emergency Information; Placement Information; 2018 and 2019 Physician's Reports; Individual Program Plan; Appraisal/Needs and Services Plan dated 12/01/2018 and 12/01/2019; Podiatrist and Psychiatrist Notes; Lower Extremity Arterial Duplex Report dated 6/05/2019; Lower Extremity Venous Report dated 6/05/2019; doctor's order of medications; LIC622 Centrally Stored Medication and Destruction Record; Medication Administration Record; Special Incident Report (SIR). admission agreement.


.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20191203145110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GERRYLAIDE MANOR
FACILITY NUMBER: 019200867
VISIT DATE: 11/03/2021
NARRATIVE
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LPA interviewed staff (S1, S2, S3), C1’s primary care physician (PCP) and family member (FM). LPA also obtained additional information from the administrator regarding the prescription and date C1 was brought to the hospital.

FM indicated R1 had 2 exploratory surgeries and found to have abscess in abdominal wall and around the rectum and had colostomy to prevent further infection. Review of C1’s Physician’s Reports revealed C1 can toilet on her own; however, the two staff assigned to C1 stated they assisted C1 on toileting and shower. . These 2 staff stated the bump started as pimple size redness on the buttock area close to the rectum few days before C1 was brought to the hospital. The redness had increase in size to a quarter coin. All three staff informed the administrator who gave instruction to monitor C1. C1 was monitored from the day the redness was first observed up until C1 was brought to the hospital. The 2 staff stated they asked the 3rd staff for assistance in checking C1. The 3rd staff stated she told the administrator to bring C1 to the hospital on the day she observed redness on C1’s groin area.

SIR indicated that PCP was called on November 18, 2019 and cream was ordered on that same day and C1 was brought to the hospital on Tuesday, November 20, 2019; however the day does not match the November 20, 2019 date. Upon verification, the administrator corrected the date he brought C1 to the hospital to Wednesday, November 20, 2019. Review of doctor's order of medication revealed the ointment was prescribed and filled on November 19, 2019 which LPA confirmed with PCP. PCP stated that call was made on November 19, 2019 and that during the call, someone saying “no pain” was heard. PCP indicated that infection can spread rapidly within 24 hours. The two staff said C1 indicated C1 was not in pain when asked.

Based on all the information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2