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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:03:35 PM

Document Has Been Signed on 02/20/2025 03:03 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/
DIRECTOR:		CASTRENCE, AIDANFACILITY TYPE:
735
ADDRESS:155 SUNSET BLVDTELEPHONE:
(510) 247-1028
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 2DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Aidan Castrence/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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On this day, February 20, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Magdalena Budol, and informed the reason for visit. LPA called and spoke over the phone with Aidan Castrence, administrator (ADM). ADM arrived at around 12:10 pm. Janae Oltmans, assistant administrator (AADM) arrived at around 12:45 pm.

LPA started the inspection with Magdalena Budol and continued with ADM. 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 in operating condition. Facility conducts drills at least every quarter, and records showed last conducted January 10, 2025. Fire extinguishers checked, observed fully charge with tags showed serviced December 2, 2024. Hot water temperature was tested in one of the bathrooms and measured at 114 degrees Fahrenheit.

Administrator to submit the following current/updated documents by March 6, 2025:
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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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: 02/20/2025
NARRATIVE
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LPA reviewed 5 staff and 2 resident records. 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 11:50 am, pizza cutter in kitchen drawer without lock; dusty and rusted floor vent in the kitchen.
-at 11:57 am, mildew in shower rooms; rusted grab bar and floor vent in the ensuite bathroom
-at 11:58 am, missing night stand drawers in resident's room.
-at 12:00 noon, soiled carpet flooring; heavily soiled floor tile grout in the dining and kitchen.
-at 12:05 pm, heavily scratched wall.
-at 1:45 pm, staff (S5) has no training on file.

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 ADM and AADM. ADM has to leave and excused himself.

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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 03:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2025 at 02:37 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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 by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in pizza cutter in kitchen drawer without lock which poses an immediate safety and/or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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2
3
4
Staff locked the item.
In addition, administrator to in-service the staff and submit proof by 2/21/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/20/2025 03:03 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/20/2025 at 02:39 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: 02/20/2025

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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Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: dusty and rusted floor vent in the kitchen; mildew in shower rooms; rusted grab bar and floor vent in the ensuite bathroom; missing night stand drawers in resident's room; soiled carpet flooring; heavily soiled floor tile grout in the dining and kitchen; heavily scratched wall
POC Due Date: 03/06/2025
Plan of Correction
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Administrator to do the following and submit pictures by 3/06/25:
(1) Have the showers, carpet, kitchen and dining floor cleaned; (2) Replace the grab bar and vent; (3) Fix or replace the nght stand drawers; (4) Replace/fix the wall.
Type B
Section Cited
CCR
80065(f)
80065 Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 S5 not having the required training on file which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator to have the staff trained and submit proof by 3/06/25.
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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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