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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 01/11/2024
Date Signed: 01/11/2024 01:41:52 PM

Document Has Been Signed on 01/11/2024 01:41 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: 1DATE:
01/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Staff Angel Riley and Bernarddo BudolTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Death Report for resident (R1) submitted on Wednesday, 1/10/24, by Aidan Castrence, administrator. Administrator also submitted with the Death Report the following documents: LIC601 Identification and Emergency Contact Information; LIC602 Physician's Report; Special Incident Report (SIR); Individual Program Plan

On this day, 1/11/24, LPA met with staff, Angel Riley and Bernardo Budol. LPA called and spoke with the administrator over the phone, and informed the reason for visit. Administrator authorized Angel Riley to sign and receive this report. While on the phone, administrator reported that he received an email on this day, 1/11/24, from resident (R2) RCEB case manager (CM) informing him that R2 passed away in the hospital yesterday, 1/10/24, at 5:45 pm. R2's Death Report to follow.

SIR and Death Report indicated that on 1/08/24, R1 attended day program. When R1 came back to the facility from program, R1 appeared tired and has little cough. Staff (S1) requested the administrator to have R1 stay home the following day so R1 can rest. On 1/08/24, R1's temperature was within normal range. On 1/09/24, R1 woke up with no change in condition, ate breakfast and lunch. At 5:15 pm, S1 called the administrator and reported that R1 would not want to drink water during lunch time. S1 reported that R1's temperature was at normal range and blood sugar at 112.1. S1 noticed R1 having phlegm while breathing and sweaty. Administrator was to have R1 brought to the hospital when S1 called him again and reported that the other staff (S2) is calling 9-1-1 because R1 threw-up then passed out. Staff performed CPR and when first responders arrived, R1 was pronounced dead at 6:11 pm.



......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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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: 01/11/2024
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LPA reviewed the documents submitted by the administrator, and conducted interviews. LPA also reviewed and obtained copies of R1's Medication Administration Record (MAR), LIC622 Centrally Stored Medication and Destruction Record, and Facility Notes.

Administrator to submit copy of death certificate when it becomes available.

No deficiency cited during today's visit.

Exit interview conducted, and copy of this report provided to Angel Riley.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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