<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 06/09/2022
Date Signed: 06/09/2022 06:00:19 PM

Document Has Been Signed on 06/09/2022 06:00 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
05:25 PM
MET WITH:Milagros Opolento/StaffTIME COMPLETED:
06:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo observed in the presence of staff, Milagros Opolento, Jesus Guinto and Rodrigo Tadeo, several flies flying around inside the facility. LPA also observed the screen door by the dining room broken. LPA spoke with Aidan Castrence, administrator, over the phone, and discussed what LPA observed. LPA informed that citations will be issued. Aidan Castrence authorized Milagros Opolento to sign and receive this report.

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

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

LIC9098 Proof of Correction form, Appeal Rights and copy of this report provided to Milagros Opolento.
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)
Page: 1 of 2
Document Has Been Signed on 06/09/2022 06:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/09/2022 at 05:36 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2022
Section Cited
CCR
80087(a)(1)

1
2
3
4
5
6
7
80087 Buildings 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
-This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to have the flies eradicated and in-service the staff. Proof to be submitted by 6/23/2022.
8
9
10
11
12
13
14
-Based on observation, the licensee did not comply with the section above. Facility has flies which poses potential health risks to persons in care.
8
9
10
11
12
13
14
Type B
06/23/2022
Section Cited
CCR80087(a)

1
2
3
4
5
6
7
80087 Buildings 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:
1
2
3
4
5
6
7
Administrator to have the screen door repaired or replaced, and submit picture by 6/23/2022.
8
9
10
11
12
13
14
-Based on observation, the licensee did not comply with the section above. LPA observed screen door broken which poses potential personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2