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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 10/07/2022
Date Signed: 10/08/2022 08:09:33 PM

Document Has Been Signed on 10/08/2022 08:09 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:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Dionisio 'Jong' Opolento
and Teresita 'Tita' Sta Maria 		TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff Dionisio 'Jong' Opolento, Teresita 'Tita' Sta Maria and Abraham Sta Maria,, and informed the purpose of visit. LPA called and spoke with Aidan Castrence, administrator, who authorized
Dionisio to be with LPA during inspection and Teresita to sign and receive this report.

Facility has an approved LIC808 Mitigation Plan on file. Administrator has not submitted the new Infection Control Plan and Monkeypox Infection Control Plan Staff were fit tested for N95 respirator last year, May 4. 2021.

LPA toured the facility inside out with Dionisio and Sta Maria. 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 and randomly selected 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. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located by the entrance door inside the recreation building with hand sanitizer and no touch temperature probe. Visitor's temperature and symptom checks and recorded on Vistior's log. Residents and staff are screened for COVID-19 symptoms, and temperature checked and recorded daily. Supplies of PPEs inspected and observed adequate for 30 days, and antigen test kits are readily available. Bathroom lavatories were observed with liquid soap and paper towels in dispensers.

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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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: 10/07/2022
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Fire extinguisher in each building were observed fully charge and tags showed serviced November 19, 2021. Hot water temperature in the bathroom in building #2 was tested and measured at 108.3 degrees Fahrenheit. Smoke detector on this building was also tested and observed operational.

LPA observed the following:
1, No "Wear Mask" posters in the recreation building and entrance doors of buidling #'s 2, 3, 4, and 5.
2. No hand washing posters in bathrooms in building #'s 3 and 5.
3. Trash bins' covers in building #'s 3 and 5 bathrooms are not touch free.
4. Rusted clothes rack and oven, dirty clothes rack. dirty folding picnic chair, blinds rod, mattress and screen door in the backyard
5. Dilapidated kitchen flooring and chipped vinyl flooring in one of the bedrooms in building # 5. Staff stated that the kitchen flooring and flooring in building # 5 are scheduled to be repaired.

The following updated/current documents to be submitted by October 21, 2022:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Infection Control Plan and Monkeypox Infection Control Plan
5. N95 Fit Testing Record

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. A $250.00 civil penalty is assessed for repeat violation of section 80087(a) within 12 month period. First citation was issued on October 13, 2021. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency and civil penalty were discussed with administrator over the phone in the presence of Dionisio and Teresita.

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

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2022 08:09 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/07/2022 at 03:24 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: 10/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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:

Deficient Practice Statement
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-Based on observation, the licensee did not comply with the section above. LPA observed the following in the backyard which poses potential safety and personal rights risks to persons in care: clothes rack, folding picnic chair; oven; mattress; screen door; blinds rod
POC Due Date: 10/21/2022
Plan of Correction
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Administrator to have the yard cleaned and submit picture by 10/21/2022.
A $250.00 civil penalty is assessed for repeat violation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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