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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 02/09/2024
Date Signed: 02/09/2024 07:26:26 PM

Document Has Been Signed on 02/09/2024 07:26 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:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Staff Angel Riley and Bernardo BudolTIME COMPLETED:
07:30 PM
NARRATIVE
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At 4:00 p.m. on this day, February 9, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Bernardo Budol, and informed the reason for visit. LPA called and spoke over the phone with Aidan Castrence, administrator. Administrator stated he can not come to the facility and authorized Angel Riley, staff, to sign and receive this report. Angel Riley arrived at around 4:15 p.m.

Administrator submitted the facility's Infection Control Plan which LPA received on March 14, 2023.

LPA started the inspection with Bernardo Budol and continued with Angel Riley. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were tested, and observed functional. Facility conducts drills at least every quarter, and records showed last conducted January 18, 2024. Fire extinguisher checked, observed fully charge with tags showed serviced December 5, 2023. Hot water temperature was tested in one of the bathrooms and measured at 116 degrees Fahrenheit.

Administrator to submit the following current/updated documents by February 23, 2024:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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: 02/09/2024
NARRATIVE
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LPA reviewed 4 staff and 1 resident records, and interviewed 2 staff and 1 resident. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I was checked and compared with the last recorded balance.

LPA observed the following:
-at 4:04 p.m., expired milk (expiration: 1/23/24) and rotten cauliflower in the refrigerator
-at 4:12 p.m., missing drawer knob in resident's (R1) room.
-at 4:16 p.m., broken sink P trap and dilapidated tiles in one of the bathrooms.
-at 4:22 p.m., over grown weeds about 1 to 1 1/2 feet tall, torn couches, empty pails of laundry soap, dusty/worn boxes. window screen, pieces of wood in the backyard.
-at 6:00 p.m., staff (S3) has no LIC503 Health Screening and TB test on file.
-at 6:10 p.m., no doctor's order on file for R1's four medications.
-at 6:20 p.m., R1 has no LIC9172 Functional Capability Assessment.

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 violations within 12 month period may result in civil penalties.

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

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: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/09/2024 07:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 06:46 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review)], the licensee did not comply with the section cited above in R1's not having octor's order on file for four medications. which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Administrator to obtain doctor's order and submit copy by 2/10/24.

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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/09/2024 07:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 06:46 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above for the following which pose a potential safety and/or personal rights risk to persons in care: missing drawer knob in resident's (R1) room; broken P trap and dilapidated tiles in one of the bathrooms; over grown weeds about 1 to 1 1/2 feet tail, torn couches, empty pails of laundry soap, dusty/worn boxes. window screen, pieces of wood in the backyard.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator to do the followjing and submit pictures by 2/23/24:
1. Fix the P trap.
2. Fix/replace the bathroom tiles.
3. Have the yard cleaned.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in S3 not having LIC503 Health Screening on file. which poses a potential health risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Administrator to have the staff health screened and submit proof by 2/23/24.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/09/2024 07:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 06:46 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not comply with the section cited above in S3 not having TB test which poses a potential health, risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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3
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Administrator to have the staff undergo TB testing and submit proof by 2/23/24.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in R1 not having LIC9172 Functional Capability Assessment on file which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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2
3
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Administrator to complete the LIC9172 and submit copy by 2/23/24.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 02/09/2024 07:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/09/2024 at 07:12 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: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group.......

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in expired milk and rooten cauliflower which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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2
3
4
Staff threw the items.
In addition, administrator to in-service the staff and submit proof by 2/10/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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