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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 09/15/2023
Date Signed: 09/15/2023 01:41:32 PM

Document Has Been Signed on 09/15/2023 01:41 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:
09/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dionisio Opulento/StaffTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Special Incident Reports (SIRs) for resident (R1) submitted by the facility. LPA met with staff, Magdalena Budol. LPA called and spoke with Aidan Castrence, administrator, over the phone, and informed the reason for visit. Administrator can not come to the facility, and authorized Dionisio Opulento, staff, to sign and receive this report. Opulento arrived after several minutes.

SIRs indicated the following:
1. SIR dated 9/04/23 with incident date 9/02/23 - On Saturday, 9/02/23, R1 was seen in his room sleeping at 2:00 pm and 4:00 pm. Staff noticed the gate was open where someone either entered or exited the facility. They checked, and R1 was not in the facility. Staff went out and checked outside the facility, and 9-1-1 was called. Dispatch stated that R1 was picked-up, and they (staff) can pick R1 up at San Leandro hospital. R1 was unharmed and brought back to the facility.
2. SIR dated 9/04/23 with incident dated 9/03/23 - On Sunday afternoon, R1 was seen in his room awake at 1:30 pm. At around 2:00 pm, staff went to the kitchen to call another staff to watch R1. As these staff were walking back to the house (building) where R1 was, they noticed from 20 yards away someone just left the facility. Staff checked and found R1 not in his room. Staff searched and called 9-1-1. A sheriff deputy came to the facility and took statements, and told the administrator that R1 tried to force himself in a public bus. R1 was picked-up by the staff from John George.

LPA conducted inspection. LPA inspected the building were R1's room was at, and observed the front gate. LPA reviewed R1's file, and obtained copies of the following: Regional Center of East Bay (RCEB) Placement Information; LIC601 Identification and Emergency Contact Information; LIC602 Physician's Report; LIC625 Appraisal/Needs and Services Plan; Individual Program Plan (IPP); Notification of Individual High Risk Behavior and Dangerous Propensities; Hospital After Visit Summary

.....continued on 809C`
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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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: 09/15/2023
NARRATIVE
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IPP indicated R1 has negative behavior of walking out of the building. Notification of Individual High Risk Behavior and Dangerous Propensities showed R1 had history of wandering away from school. LIC602 Physician's Report revealed R1 can not leave the facility unassisted.

During today's visit, LPA observed all entrance/exit door of the building where R1's room is and front gate are without auditory signals.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due dates, and any repeat violation within 12-month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with administrator over the phone in the presence of Dionisio Opulento.

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: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/15/2023 01:41 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/15/2023 at 01:02 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: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2023
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 9/16/23:
1. Re-assess resident and provide the care needs immediately.
2. In-service staff.
3. Schedule an Interdisciplinary Meeting with Regional Center of East Bay.
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-Based on interview and review of records, the licensee did not comply with the section above for R1 who was able to AWOL which posed immediate risk to persons in care.
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Type A
09/16/2023
Section Cited
CCR80077.3(a)

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80077.3 (a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door
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Administrator to have auditory signals installed in the building and front gate, Pictures to be submitted by 9/16/.23.
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is opened. The fencing and devices must not substitute for appropriate staffing.
-This requirement is not met as evidenced by: Based of observation, the licensee did not comply with the section above, for entrance and exit doors not having auditory signals which posed immediate risk 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: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023


LIC809 (FAS) - (06/04)
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