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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:26:33 PM

Document Has Been Signed on 01/10/2023 02:26 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: 18DATE:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Adelaide Castrence/LicenseeTIME COMPLETED:
02:25 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) and Death Report for resident (R1) submitted by the facility to the Department on 1/04/23. LPA met with Adelaide Castrence, licenseee, and informed the purpose of visit. LPA called and spoke with Aidan Castrence, administrator, over the phone.

SIR and Death Report indicated that R1 was sent out to the hospital on 11/12/22 and diagnosed with liver cancer. R1 was discharged back to the facility on 12/09/22 on hospice care. Reports further indicated that the facility has hospice waiver. However, hospice waiver was approved on previous license not on this current license. This was discussed with the licensee and administrator.

On this same day, 1/10/23, LPA reviewed R1's file, obtained copies of documents, and conducted interview. Review of records confirmed R1 was on hospice care which was also confirmed with staff when R1 passed away.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with administrator over the phone and with licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to the licensee.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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 01/10/2023 02:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/10/2023 at 02:02 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: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited
CCR
85075.2(a)

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85075.2 Facility Hospice Care Waiver
(a) In order to accept or retain terminally ill clients and permit them to receive care from hospice, the licensee shall have requested in writing and been granted a Facility Hospice Care Waiver from the Department.
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Licensee and administrator to read the Regulations and submit self-certification. In the future, a hospice waiver will be submitted if the facility deemed to be able to provide care to hospice resident.. POC to be submitted by 1/17/23.
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This requirement is not met as evidenced by:

-Based on records review and interview, the licensee did not comply with the section above for admitting R1 back under hospice care when facility has no approved hospice waiver.
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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: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023


LIC809 (FAS) - (06/04)
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