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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 04:36:50 PM

Document Has Been Signed on 11/08/2023 04:36 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 AM
MET WITH:Angel Riley/StaffTIME COMPLETED:
04:40 PM
NARRATIVE
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While at the facility for other reason and upon review of documents and interviews, Licensing Program Analyst (LPA) Delmundo observed the following:
1. Staff (S1) is fingerprinted and cleared but not associated to this facility.
2. Staff (S2) does not have first aid training

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 violation within 12-month period may result in civil penalty.

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

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Angel Riley.
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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Document Has Been Signed on 11/08/2023 04:36 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 11/08/2023 at 03:27 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 B
11/22/2023
Section Cited
CCR
80065(i)(2)

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80065 Personnel Requirements
(i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f).
-This requirement is not met as evidenced by:
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Adminisrator to have S1 associated and submit proof by 11/22/23.
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-Based on record review, the licensee did not comply with the section above for S1 not associated to this facility which poses potential safety and/or personal rights risks to persons in care.
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Type B
11/22/2023
Section Cited
CCR80075(f)

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80075 Health Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
-This requirement is not met as evidenced by:
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Administrator to have S2 first aid trained and submit copy of certificate by 11/22/23,
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-Based on interview and record review, the licensee did not comply with the section above for S2 not having first aid training which poses potential health and/or personal rights risks to persons 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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