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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 10/17/2023
Date Signed: 10/17/2023 07:28:50 PM

Document Has Been Signed on 10/17/2023 07:28 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:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Staff Dionisio OpulentoTIME COMPLETED:
07:30 PM
NARRATIVE
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On this day, October 17, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection and met with staff, Demetrio Malonzo and Teresita 'Tita' Sta Maria. LPA called and left message on Aidan Castrence's (administrator) voice mail who returned and authorized Dionisio Opulento to be with LPA during inspection, and sign and receive this report. Dionisio Opulento arrived after several minutes. Administrator arrived at 5:00 pm.

Facility has Infection Control Plan that was submitted by the administrator and received by LPA on October 26, 2022.

LPA toured the facility inside out. 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.

Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in building # 2 was tested and measured at 112.9 degrees Fahrenheit. Staff stated they conduct disaster drills monthly, however, last drills on record was dated 5/17/23.

LPA reviewed 5 staff and 5 residents files, and interviewed 3 residents and 3 staff. Medications checked, and compared with records and doctor's orders. Residents cash resources records reviewed.

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.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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: 10/17/2023
NARRATIVE
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LPA observed the following:
-at 1:37 pm, missing drawer knob in one of the resident rooms in building # 3.
-at 1:40 pm, medications unlocked in unlocked staff room in building # 3.
-at 1:46 pm, paper towel holder and toilet paper towel holder broken in one of the bathrooms in building # 4.
-at 2:01 pm, dilapidated closet door and wall in the residents room in building # 5.
-at 5:23 pm, R3's LIC602 dated 2023 and 2021 didn't indicate ambulatory status.

Administrator to submit the following updated/current documents by October 31, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety bond coverage

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

Deficiencies and plan and proof of corrections were discussed with the administrator and 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: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/17/2023 07:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/17/2023 at 06:33 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for bleach, cleaning supplies and staff medications unlocked which pose immediate safety risks to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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2
3
4
Staff locked the staff room and cabinet immediately.
In addition, administrator to in-service the staff and submit copy of trainining topics with attendees signatures by 10/18/23.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/17/2023 07:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/17/2023 at 06:33 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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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2
3
4
Based on observation, the licensee did not comply with the section cited above for missing drawer knob, paper towel holder and toilet paper towel holder broken, dilapidated closet door and wall in the residents room which pose a potential personal rights risks to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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3
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Administrator to replace the paper towel & toilet paper holders and fix/repair the drawer, wall and closet door. Pictures to be submitted by 10/31/23..
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above for 1 out of 5 residents' ambulatory status not indicated on LIC602 which poses a potential health and/or safety risks to person in care.
POC Due Date: 10/31/2023
Plan of Correction
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Administrator to have the LIC602 updated and submit copy by 10/31/23,
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/17/2023 07:28 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 10/17/2023 at 07:06 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)(2)
80023 Disaster and Mass Casualty Plan
(d)(2) The drills shall be documented and the documentation maintained in the facility for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above for not having records of the drills conducted after May 2023 which poses a potential safety risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Administrator to have records completed and submit self-certification 10/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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