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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 09/27/2024
Date Signed: 09/27/2024 06:55:17 PM

Document Has Been Signed on 09/27/2024 06:55 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: 16DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Charito Delos Reyes/Staff and
Janae Oltmans/Assistant to the Administrator		TIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On this day, September 27, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection and met with staff, Charito Delos Reyes. LPA called and spoke over the phone with Aidan Castrence, administrator (ADM), who stated he can not come to the facility and gave permission to Janae Oltmans, assistant to the administrator (AADM) to be with LPA during inspection. AADM arrived after about 20 minutes. LPA also met with other staff, Conchita Dela Cruz, Gloria Gutierrez and Demetrio Malonzo.

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

LPA started the inspection with Charito Delos Reyes and continued 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. 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 tested and observed in operating condition. Hot water temperature in building # 5 was tested and fire extinguishers checked.

LPA interviewed 3 residents.

LPA observed the following:
-at 3:50 pm, flies flying around the kitchen and dining area.
-at 4:02 pm, rotten broccolli with very strong pungent smell, expired soy milk (expiration date: 7/31/24), coconut with mold, 2 large empty sacks of rice inside the refrigerator.
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.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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: 09/27/2024
NARRATIVE
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-at 4:05 pm, heavily stained cutting boards.
-at 4:20 pm, hot water temperature at 102.6 degrees Fahrenheit.
-at 4:22 pm, Lysol in the bathroom cabinet in bldg # 5.
-at 4:25 pm, bathtub, sink, broken aquarium, rusted grill, pieces of metal, pieces of pipes in the backyard.
-at 4:29 pm, mildew on the shower and shower door in bldg # 4.
-at 4:44 pm, Voltaren in resident's room in bldg # 2.

Administrator to submit the following updated/current documents by October 11, 2024:
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. A $250.00 civil penalty each for deficiency section #s 80087(g) and 80087(a) are assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with the ADM over the phone in the presence of Charito Delos Reyes. ADM authorized Delos Reyes to sign and receive this report.

Due to time constraint, LPA will come back to continue the inspection.

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: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 09/27/2024 06:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/27/2024 at 05:55 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: 09/27/2024

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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2
3
4
Based on observation, the licensee did not comply with the section cited above in Lysol in the bathroom cabinet in bldg # 5 and Voltaren in resident's room in bldg # 2 which pose an immediate health, safety and/or personal rights risk to persons in care.
This is a repeat violation within 12-month period. A citation was issued on 10/17/23. A $250.00 civil penalty is assessed.
POC Due Date: 09/28/2024
Plan of Correction
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Staff locked the items.
In addition, administrator to in-service the staff and submit proof by 9/28/24.
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 in the following which pose an immediate health and/or personal rights risks to persons in care: rotten broccolli; expired soy milk; coconut with mold
POC Due Date: 09/28/2024
Plan of Correction
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Staff threw the items.
In addition, administrator to in-service the staff and submit proof by 9/28/24.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 09/27/2024 06:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/27/2024 at 05:55 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: 09/27/2024

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 in the following which pose a potential health, safety and/or personal rights risks to persons in care: bathtub, sink, broken aquarium, rusted grill, pieces of metal, pieces of pipes in the backyard; mildew on the shower and shower door in bldg # 4.
This is a repeat violation within 12-month period. A citation was issued on 10/17/23. A $250.00 civil penalty is assessed.
POC Due Date: 10/11/2024
Plan of Correction
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Administrator to have the yard and bathroom/shower cleaned and submit pictures by 10/11/24.
Type B
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 in flies flying around the kitchen and dining area which pose a potential health risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Administrator to have door mesh installed and submit pictures by 10/11/24.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/27/2024 06:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/27/2024 at 05:55 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 in hot water temperature at 102.6 degrees Fahrenheit which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Administrator to have the temperature adjusted within Regulations range and submit proof by 10/11/24.
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above in 2 large empty sacks of rice inside the refrigerator which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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4
Items were removed from the refrigerator.
In addition, administrator to in-service the staff and submit proof by 10/11/24.
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/27/2024 06:55 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/27/2024 at 05:55 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: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(19)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (19) All equipment, fixed or mobile, dishes, and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in heavily stained cutting boards which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
1
2
3
4
Administrator to purchase new cutting boards and submit proof of purchase and pictures by 10/11/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
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