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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 10/13/2021
Date Signed: 10/13/2021 03:12:49 PM

Document Has Been Signed on 10/13/2021 03:12 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:
10/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Teresita Sta Maria/StaffTIME COMPLETED:
12:00 PM
NARRATIVE
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While conducting investigation of complaint (15-AS-20191203145110), Licensing Program Analyst (LPA)Delmundo observed at about 10:40 am the recreation/activity room's floor dirty and with feces. LPA called and spoke with Aidan Castrence, administrator, over the phone and informed of what LPA observed.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan of correction were discussed with Castrence who authorized Teresita Sta Maria to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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Document Has Been Signed on 10/13/2021 03:12 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/13/2021 at 02:19 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: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

-This requirement is not met as evidenced by:
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Staff mopped part of the floor with feces while LPA is still at the facility.

Administrator to do the following and send proof by 10/27/2021:
1. Have the room cleaned thoroughly and send pictures.
2. In-service the staff and submit proof.
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-Based on observation, the licensee did not comply with the section above. LPA observed the recreation/activity room's floor dirty and with feces which poses potential health and personal rights risks 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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