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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 06/09/2022
Date Signed: 06/09/2022 05:58:05 PM

Document Has Been Signed on 06/09/2022 05:58 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 MANOR IIIFACILITY NUMBER:
019200868
ADMINISTRATOR:CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:155 SUNSET BLVDTELEPHONE:
(510) 247-1028
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
06/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Milagros Opolento/StaffTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced case management visit pertaining to an incident and death report submitted to Community Care Licensing by the facility. LPA met with staff, Milagros Opolento, Jesus Guinto and Rodrigo Tadeo, and informed the purpose of visit. LPA called and spoke with Aidan Castrence, administrator, over the phone who authorized Milagros Opolento to sign and receive this report.

Special Incident Report (SIR) indicated that on Thursday, May 26, 2022, resident (R1) ate only 70% of his dinner. The following day, May 27, 2022, R1 refused to eat breakfast and take medications. R1's doctor was notified and the doctor ordered for R1 be given Ensure. 9-1-1 was called in the afternoon of May 27. 2022, and R1 was sent out to the hospital where R1 passed away on May 29,2022.

LPA discussed the circumstances of the resident's (R1) history and condition. LPA reviewed and obtained documents from the resident's file including LIC602 Physician's Report, Appraisal/Needs and Services Plan, Behaviorist Assessments, doctor's visit and podiatrist notes.

No deficiency cited for this visit.

Exit Interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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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