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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200868
Report Date: 11/08/2023
Date Signed: 11/08/2023 04:34:59 PM

Document Has Been Signed on 11/08/2023 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: 3DATE:
11/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff Angel RileyTIME COMPLETED:
03:30 PM
NARRATIVE
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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 Sunday, 11/05/23, by Aidan Castrence, administrator. Administrator also submitted with the Death Report including but not limited to the following documents: LIC601 Identification and Emergency Contact Information; LIC602 Physician's Report; Special Incident Report (SIR); Individual Program Plan; hospital Visit Summary dated 10/28/23-10/29/23.

LPA met with staff, Angel Riley. LPA also met with other staff, Gloria Gutierrez and Bernardo Budol. LPA called and spoke with the administrator over the phone, and informed the reason for visit. Administrator can not come to the facility, and authorized Angel Riley to sign and receive this report.

Documents indicated R1 came back to the facility on 1029/23 after being hospitalized on 1028/23 and was diagnosed with Syncope, likely due to dehydration. On 11/04/23, R1 ate dinner and was given medications. When staff, S1, went to R!'s room to check, R1 was observed on the floor. S1 performed CPR while S2 called 9-1-1. First responders took over the CPR upon arrival. R1 was pronounced dead at 7:57 pm.

On this day, 11/08/23, LPA reviewed R1's records and Medication Administration Record (MAR) and conducted interviews. LPA obtained copies of MAR and LIC622 Centrally Stored Medication and Destruction Record.

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


..continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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: 11/08/2023
NARRATIVE
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LPA observed the following:
-Hospital After Visit Summary dated 10/28/23 - 10/29/23 showed R1's two (2) previous medications no longer on the list, however, MAR showed these 2 medications were still administered until 11/04/23.
-Hospital After Visit Summary showed 1 medication on the list but this medication was only given until 10/31/31. S2 stated Home Health came to visit R1 and the said medication was discontinued; however, there's no discontinued order on file.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with administrator over the phone in the presence of 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: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2023 04:34 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/08/2023 at 03:04 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

-This requirement is not met as evidenced by:
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Administrator to do the following:
1. Check other residents' documents and ensure medications are properly administered.
2. In-service the staff and submit proof by 11/09/23.
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-Based on records review, the licensee did not comply with the section above for giving R1 2 medications no longer on the medication list and not giving 1 medication that is still on the list. These posed immediate health risk to person in care,
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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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023


LIC809 (FAS) - (06/04)
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