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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200867
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:30:43 PM

Document Has Been Signed on 01/17/2025 04:30 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: 15DATE:
01/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Janae Oltmans/StaffTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On this day, 1/17/25, while at the facility for other reason, Aidan Castrence, administrator (ADM), informed Licensing Program Analyst (LPA) Delmundo that resident (R1) passed away this morning at around 6:30 a.m. ADM stated that 9-1-1 was called and the first responders pronounced R1 dead at around 6:30 a.m. ADM stated that Adelaide Castrence, license, and R1's mother came. R1's body was picked-up by the mortuary. ADM stated he will send to LPA the Death Report, and that he can not come to the facility to meet LPA and authorized Janae Oltmans, assistant to the administrator, to sign and receive this report.

On this same day, LPA reviewed R1's file, doctor's order of medications, checked the medications and compared with Medication Administration Records (MAR). LPA conducted interviews and obtained copies of R1's following documents: LIC601 Identification and Emergency Contact Information; Face Sheet; LIC602 Physician's Report; LIC625 Appraisal/Needs and Services Plan; list of medications; MAR; facility notes

No deficiency cited during this visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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