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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:27:01 PM

Document Has Been Signed on 01/17/2025 04:27 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/
DIRECTOR:		CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:261 MEDFORD AVETELEPHONE:
(510) 278-9766
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 32CENSUS: 15DATE:
01/17/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Janae Oltmans/StaffTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On this day, 1/17/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 2 complaint (Complaint # 15-AS-20250116091702). LPA met with Janae Oltmans, assistant to the administrator (AADM). LPA called and spoke over the phone with Aidan Castrence, administrator (ADM) and informed the reason for LPA's visit. ADM stated he cannot come to the facility and authorized AADM to sign and receive this report.

LPA informed ADM that the Department received information about Regional Center of East Bay (RCEB) terminating the vendorization of this facility effective March 2025 and all residents will be moved-out before the effective date of devendorization.

LPA toured the facility inside out with AADM. The facility has six buildings (building #'s 2, 3, 4, 5, recreation building and office). LPA inspected the buildings except the office. LPA inspected the bathrooms/toilets, residents' bedrooms in building #'s 2, 3, 4 and 5. LPA also inspected the recreation building, common areas, dining room, kitchen, hallways, side and backyard.

LPA observed the following:
-at 11:45 a.m, razor in the drawer in the recreation building.
-at 12:09 p.m., medication, nail polish remover, Lysol spray in unlocked staff bedroom in bldg # 2.
-at 12:16 p.m., moldy toilet in bldg # 3.
-at 12:20 p.m., 2 non-slid mats with mildew in the bathroom in bldg # 4.
-at 12:25 p.m., moldy shower chair outside bldg # 5.
-at 12:30 p.m., moldy broken swing and piece of glass in the backyard.

......continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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: 01/17/2025
NARRATIVE
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Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. A $250.00 civil penalty is assessed each for deficiency section 80087(a) and 80087(g) for repeat violations within 12 month period. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalties were discussed with the ADM in the presence of AADM.

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 04:27 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/17/2025 at 02:09 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: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2025
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
-This requirement is not met as evidenced by:
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AADM locked the razor and staff bedroom.

In addition, administrator to do in-service training and submit proof by 1/18/25.

A $250.00 civil penalty is assessed for repeat violation within 12 month period.
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-Based on observation, the licensee did not comply with the section above in the the following: unlocked razor; medication, nail polish remover and Lyol spray in unlocked staff bedroom which posed an immediate health, safety and/or personal rights risks to persons in care.
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A citation was issued on 9/27/24.
Type B
01/31/2025
Section Cited
CCR80087(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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Administrator to do the following and submit pictures by 1/31/25:
1. Throw away the non-slid mats and replace with new one.
2. Have the toilet cleaned.
3. Throw away the moldy shower chair and have the yard cleaned.
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-Based on observation, the licensee did not comply with the section in the following which pose a potential safety and/or personal rights risks to persons in care: moldy toilet; non-slid mats with mildew; moldy broken swing and piece of glass in the backyard; moldy shower chair
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A $250.00 civil penalty is assessed for repeat violation within 12 month period.
A citation was issued on 9/27/24.
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: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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