<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 11/03/2021
Date Signed: 11/03/2021 05:46:47 PM

Document Has Been Signed on 11/03/2021 05:46 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:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Aidan Castrence/AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Teresita Sta Maria. LPA called and spoke with Aidan Castrence, administrator, who arrived after several minutes. LPA informed the purpose of visit..

The facility consists of six buildings (building #'s 2, 3, 4, 5, recreation building and office). Facility has a completed COVID-19 mitigation plan that was approved on May 2021.

LPA started the inspection with Teresita Sta Maria and continued with Aidan Castrence. LPA observed screening station located by the entrance door inside the recreation building with visitor's log, hand sanitizer and no touch temperature probe and disposable gloves. Routine symptom screening (+/-) temperature and symptom checks are done for all staff, clients and visitors. Clients are screened for COVID-19 symptoms and temperature checked daily. Infection control designated leader is the administrator.

Adequate supply of centrally stored PPEs was observed. There were at least 7 days of nonperishable and 2 days of perishable foods. Fire extinguisher in each building were observed fully charge; however, tags showed serviced May 15, 2020. Hot water temperature in the bathroom in building #2 was tested and measured at 108.20 degrees Fahrenheit.

LPA observed the following:
1. No sneeze and cough etiquette poster in recreation building.
2. No "Welcome Visitors" poster on facility entrance.
3. Trash can without lid in building # 4's bathroom and trash can's lid in the kitchen is not "touch free".
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 11/03/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA verified and Aidan indicated all staff were fit tested for N95 respirator; however, he does not have copy of the record.

LPA requested for copies of the following updated documents to be submitted to Community Care Licensing (CCL) by November 17, 2021:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan
3. Surety bond coverage.

LPA discussed with Aidan the kitchen cabinets paint that appeared worn out. Aidan indicated that there's a plan to upgrade and replace the kitchen cabinets and/or expand the kitchen and dining area.

No deficiency cited on this day.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4