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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 09/30/2024
Date Signed: 09/30/2024 05:34:09 PM

Document Has Been Signed on 09/30/2024 05:34 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:
09/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Aidan Castrence/AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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At 3:10 pm on this day, September 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual inspection that was started September 27, 2024. LPA called and spoke with Aidan Castrence, administrator (ADM), and informed the reason for visit. ADM arrived after about 5 minutes. ADM administrator certificate is current (certificate # 7002450735; expiration:11/16/25)

Facility conducts disaster drills and records showed last conducted August 22, 2024.

LPA reviewed 5 residents and 5 staff records. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Residents P&I checked and compared with the last recorded balance.

LPA observed the following:
-at 4:20 pm, resident (R2) has order for 1 medication, 300 mg morning; 400 mg bedtime, but the medication on hand is 300 mg twice daily.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalty.

Deficiency and plan and proof of correction were discussed with the ADM.

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: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 05:34 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 09/30/2024 at 05:26 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: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in resident (R2) has order for 1 medication, 300 mg morning; 400 mg bedtime, but the medication on hand is 300 mg twice daily which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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Administrator to check with the doctor for correct/updated order and submit proof by 10/01/24.
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: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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