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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:34:37 PM

Document Has Been Signed on 02/27/2023 04:34 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 MANOR IIIFACILITY NUMBER:
019200868
ADMINISTRATOR:CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:155 SUNSET BLVDTELEPHONE:
(510) 247-1028
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Staff Milagros Opulento
and Dionisio Opulento		TIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Milagros Opulento and Dionisio Opulento, and informed the purpose of visit. LPA called and spoke with Aidan Castrence, administrator, who authorized Milagros Opulento to be with LPA during inspection, and sign and receive this report,

Facility has an approved LIC808 Mitigation Plan. Facility has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out with Milagros Opulento. LPA inspected the living room, dining area, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed all throughout the facility. Bathroom lavatories were observed with liquid soap. Trash cans were observed with touch free lids.

Fire extinguisher checked, and observed fully charge with tag showed serviced December 20, 2022. Hot water temperature in one of the common bathrooms was tested, and measured at 115.9 degrees Fahrenheit.

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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 III
FACILITY NUMBER: 019200868
VISIT DATE: 02/27/2023
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LPA observed the following:
1. Central storage for medications unlocked.
2. Unlocked basement where insect killer, pail of paint, rat killer and Clorox bleach are kept
3. Cleaning supplies cabinet unlocked.
4. Unlocked kitchen drawer where knives are kept.
5. No paper towel nor paper tower holders in 2 bathrooms,
6. One of the staff not wearing mask inside the facility.
7. Supplies of PPEs not sufficient for 30 days for 3 staff. No N95 respirator, Supplies on hand: 5 face shields; 15 disposable gowns; 48 surgical masks.

Adminstrator to submit the following by March 13, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of $3M liability insurance.
5. Current N95 fit testing records/certificates
6. Proof of Surety bond coverage.
7. LIC9282 Infection Conrol Plan

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with administrator over the phone.

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: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2023 04:34 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/27/2023 at 04:10 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 III
FACILITY NUMBER: 019200868

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings 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 byL
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for unlocked kitchen drawer, basement and cleaning supplies cabinet which pose an immediate safety risks to persons in care.
POC Due Date: 02/28/2023
Plan of Correction
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Staff locked the cabinets & basement,
In addition, administrator to do in-service training, and submit copy of training topics with attendees sgiantures by 2/28/23.
Type A
Section Cited
CCR
80075(j)(3)
80075 Health Related Services
(j)Medications shall be centrally stored under the following circumstances:
(3) Because of physical arrangements and the condition or the habits of persons in the facility, the medications are determined by either the administrator or by the licensing agency to be a safety hazard.

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 for unlockeed medication storage which poses an immediate health and safety risks to persons in care.
POC Due Date: 02/28/2023
Plan of Correction
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Staff lock the cabinet.
In addition, administrator to in-service the staff, and submit cipy of training topic with attendees signatures by 2/28/23.
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: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023


LIC809 (FAS) - (06/04)
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