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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 09/20/2021
Date Signed: 09/20/2021 05:11:37 PM

Document Has Been Signed on 09/20/2021 05:11 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:GERRYLAIDE MANORFACILITY NUMBER:
019200867
ADMINISTRATOR:CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:261 MEDFORD AVETELEPHONE:
(510) 278-9766
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 32CENSUS: 20DATE:
09/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Teresita Sta Maria/Staff TIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to the Special Incident Report (SIR) for resident (R1) submitted by the facility to the Department. LPA met with staff Demetrio Malonzo and Marciana Malonzo, and later met with another staff, Teresita Sta Maria. LPA called and spoke with Aidan Castrence, administrator, over the phone and informed the purpose of visit. Castrence can not come to the facility and authorized Teresita Sta Maria to sign and receive this report.

SIR indicated that R1 was in the hospital since August 25, 2021. The family has taken over R1's care and informed Castrence that R1 had a tumor. R1 eventually passed away.

LPA reviewed the other SIR the Department received which revealed R1 who had an appointment scheduled for August 25, 2021 and was taken to the emergency as R1's stomach was observed was getting bigger and being bloated.

On this day, September 20, 2021, LPA reviewed R1's file, conducted interviews, and obtained copies of documents. Staff interviewed indicated R1 can toilet on own which is consistent with the LIC602 Physician's Report on file; however, this document on file was dated February 17, 2018. Castrence indicated R1 has a current LIC602 but iss not on R1's file. LPA observed the most current Appraisal/Needs and Services Plan was dated December 1, 2019.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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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: GERRYLAIDE MANOR
FACILITY NUMBER: 019200867
VISIT DATE: 09/20/2021
NARRATIVE
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Deficiencies and plan and proof of correction were discussed with Castrence over the phone in the presence of Sta Maria.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Sta Maria.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/20/2021 05:11 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/20/2021 at 04:24 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: GERRYLAIDE MANOR
FACILITY NUMBER: 019200867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2021
Section Cited
CCR
85068.2(b)(1)(G)(1)

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85068.2 Needs and Services Plan
(b) (1)(G) The licensee shall document....1. The licensee shall document the initial assessment based on information available at the time of the assessment. This information shall be maintained and brought current thereafter as needed.
This requirement is not met as evidenced by:
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R1 passed away September 2021.

Administrator to review and update all of residents' records and submit by 10/04/2021 a self-certification indicating records are completed.
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-Based on interview and records review, the license did not comply with the section cited above for not having a current apraisal for R1 which posed potential health risk to person in care.
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Type B
10/04/2021
Section Cited
CCR80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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Administrator to ensure all residents documents are in their corresponding file and submit self-certication by 10/04/2021.
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-Based on interview and records review, the license did not comply with the section cited above for not having the most current LIC602 on R1's file.
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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