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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200868
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:42:32 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2024 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20241122090018
FACILITY NAME:GERRYLAIDE MANOR IIIFACILITY NUMBER:
019200868
ADMINISTRATOR:CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:155 SUNSET BLVDTELEPHONE:
(510) 247-1028
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 2DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Janae Oltmans- Assistance AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff inappropriately barricade resident's door.
Staff do not allow residents to have access to food while in care.
INVESTIGATION FINDINGS:
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On 11/26/2024 at 8:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation in regard to the allegations above. LPA met with care staff Bernardo Budol and spoke with Administrator, Aidan Castrence over the phone and explained the purpose of the visit. Later Assistance Administrator, Janae Oltmans later arrived. Administrator was not available to attend and gave verbal permission for Janae to sign the report.

During the course of the investigation, LPA reviewed staff files and clients files. LPA interviewed S1, S2, S3, S4 and toured the facility.

*** REPORT CONTINUES ON LIC 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20241122090018
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 019200868
VISIT DATE: 11/26/2024
NARRATIVE
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Allegation: Staff inappropriately barricade resident's door.

LPA observed the facility have two and do not have any client, due to client at attending day program. LPA toured facility including but not limited to all client’s room, kitchen, living room, bathroom, and food pantry. Client’s rooms are kept clean, and food pantry are unlocked and accessible for clients.

Allegation: Staff do not allow residents to have access to food while in care.

LPA interviewed 4 staff, 4 out of 4 stated that R2 is the one that put the chair in front of R1 door and in front of the food pantry. Due to R2 new develop behavior. Staff redirected R2 when R2 put chair in front of R1 door and food pantry. Facility has schedule R2 behavior specialist to discuss R2 newly develop behavior. . LPA observed food pantry is keep unlocked and clients can assess the food pantry at all time.

This agency has investigated the above allegations. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview conducted, a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
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