"He would've got to see his grandson graduate in December," said Scott Akrie mourning the loss of his father. "My parents were about a month away from their 65th wedding anniversary."
RELATED: 10th COVID-19 death confirmed at Gateway nursing home in Hayward
Costell Akrie died of COVID-19 a mere three weeks after being temporarily admitted into the Gateway Care and Rehabilitation Center in Hayward.
"They were so short on staffing that no one could go into his room in order to give him the phone," he said. "The phone would ring and ring and ring...we would call the nurses station. Until we would give up."
In the last five days of his father's life, Akrie was unable to speak to him.
"We never even said goodbye."
According to an ABC7 analysis of payroll data, Gateway Care & Rehabilitation Center is one of 25 nursing facilities in Alameda County that failed to meet staffing standards in the last quarter of 2019. Under federal law, registered nurses are required to report at least eight consecutive hours. But, there were more than 500 instances of underreporting across all 25 facilities in the county between October and December last year. The most in the Bay Area.
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To put it in perspective, 21 facilities had registered nurses that failed to report any hours. It's unclear if these employees just didn't show up to work or other reasons prompted the underreporting. Gateway was one of 21 facilities.
"People who did come to work had 20 to 25 patients they were attending to," said Akrie.
The ABC7 I-Team reached out to the facility but has yet to hear back. In April, the I-Team obtained text messages from the owners of Gateway, Prima and Anthony Thekkek. One text said: "We immediately need licensed staff and CNAs at Gateway. What can you all do to help?"
VIDEO: Families threaten legal action after loved ones die of COVID-19 at Hayward nursing home
But, according to our analysis, Gateway's staffing shortage was a problem well before April. The facility failed to meet the state's minimum staffing score several times in 2019. A problem that should've been flagged and enforced by the California Department of Public Health.
ABC7 reached out to the state agency on the phone.
Stephanie: "Why isn't your team identifying these facilities that clearly fell below the minimum requirements?"
In statement an agency spokesperson wrote: "In addition to routine inspections, CDPH regularly conducts staffing audits at health facilities across the state to ensure they are complying with the minimum staffing standards, as applicable, of 3.5 nursing hours per patient day, with 2.4 of those hours being provided by certified nursing assistants. The staffing audits pull staffing data for 24 sample dates to determine compliance. If the facility fails to meet the staffing standard, CDPH issues an administrative penalty. If the facility is non-compliant for 5 - 49 percent of the audited days, the penalty is $15,000; if the facility fails to meet the requirements of 50 percent or more of the audited days, the penalty is $30,000."
CDPH declined our request for an interview. But, ABC7 will continue following up with the agency to see why the following facilities haven't been flagged.
"This is squarely within the work they should be doing," said Tony Chicotel, a staff attorney with California Advocates for Nursing Home Reform. "I actually think this would save them a lot of time. It's a great way to turn publicly available data into a dashboard for facilities that need the help."
Facilities like Gateway - where 65 people tested positive for COVID-19 and more than a dozen residents have died following the outbreak. Now, families want change to happen.
"He always had a cause in his life, the irony is he's kind of leaving us with one," Akrie said. "Our goal is to make sure this doesn't happen again."
Take a look at for a look at more stories by Dan Noyes and the ABC7 News I-Team.
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