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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 11/17/2021
Date Signed: 11/17/2021 12:50:53 PM

Document Has Been Signed on 11/17/2021 12:50 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:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Teresita Sta Maria/StaffTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived to the facility unannounced to conduct a case management visit to follow-up on a self reported Special Incident Report (SIR) involving resident (R1). The report indicated that on November 7, 2021 at around 4:00 pm, when staff was going to check on R1, R1 was nowhere to be found. Staff went out of the facility and when unable to find R1, asked other staff for help in searching and called Aidan Castrence, administrator. Aidan went to the facility and on the way, called the police to file a missing person report. Alameda County Sheriff police arrived and told staff that R1 may have been found. After checking R1's picture, it was confirmed that R1 was at the hospital with no injuries and ready to be discharge.

On this day, November 17, 2021, LPA met with Teresita Sta Maria, staff. LPA called and spoke with Aidan Castrence and informed the purpose of visit. Aidan authorized Teresita to sign and receive this report.

LPA conducted interviews, reviewed and obtained copies of R1's documents including but not limited to LIC602 Physician's Report, Addendum to Individual Program Plan (IPP), IPP, Appraisal Needs and Services Plan, Notification of Individual High Risk Behavior and Dangerous Propensities and hospital discharge document. LIC602 revealed R1 can not leave the facility unassisted. Record showed R1 has history of AWOL.

Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction along with the LIC9098 Proof of Correction form and any repeat violation within 12-month period may result in civil penalty.

.....continued on 809C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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 11/17/2021 12:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/17/2021 at 12:15 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: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Administrator to do the following and submit proof by 11/18/2021:
1. Effective immediately, facility will provide 1:1 supervision while R1's case manager is finding for new placement and submit list of staff scheduled in providing 1:1.
2. In-service the staff.

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-Based on records review and interviews, the licensee did not comply with the section above. R1 was not provided the required supervision which resulted to R1 able to AWOL which posed immediate safety risks to person in care.
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3. Update Appraisal/Needs and Services Plan.

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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: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


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: 11/17/2021
NARRATIVE
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Deficiency and plan and proof of correction were with discussed with Aidan Castrence over the phone in the presence of Teresita Sta Maria.

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: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3