197603675-12-1-2021-29-AS-JAPL-C9NU7Y-20211213142040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603675
Report Date: 12/01/2021
Date Signed: 12/01/2021 08:12:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2020 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20200507140728

FACILITY NAME:	GILMAR MANOR		FACILITY NUMBER:	197603675
ADMINISTRATOR:	VLADIMIR CHERTOK		FACILITY TYPE:	735
ADDRESS:	15152 VICTORY BLVD.		TELEPHONE:	(818) 989-2651
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY:	78	CENSUS: 68	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Gabriela Chavez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Failure to meet client's needs
Failure to provide adequate supervision

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/01/2021, Licensing Program Analyst (LPA), Sandra Urena arrived at 9:30 a.m. for an unannounced subsequent complaint visit to investigate the above allegations. LPA Urena met with Gabriela Chavez, Assistant Administrator and facility representative, and informed them for the reason of the visit.

On 5/18/2020, Licensing Program Analyst (LPA) Eva Miller initiated a complaint investigation for the allegations listed above. The complaint investigation was conducted via FaceTime with Gabriela Chavez, the facility manager. The complainant alleged that the Client's needs for emotional support and mental health guidance are not being met by facility staff and that a lack of supervision by staff results in altercations between clients.

Continues on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20200507140728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GILMAR MANOR	FACILITY NUMBER: 197603675
	VISIT DATE: 12/01/2021

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
26
27
28
29
30
31
32

During today’s visit, at 10:00am, LPA Urena and Gabriela Chavez conducted a physical plant tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition.

COMMON SPACES: The LPA and Ms. Chavez observed the activity room, and dining room. At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed the required postings in the hallway. The LPA observed sanitizer interspersed throughout the facility.

The LPA reviewed staff and residents' files and found them to be in order at this time.

LPA Urena conducted residents and staff interviews from 11:00 a.m. to 2:00 p.m.

Regarding the allegation: Facility staff failed to meet clients’ needs. It is alleged that facility staff are not caring for clients’ well-being and welfare. LPA Urena interviewed 11 residents, and six staff members. At the time of the interview, 10 residents reported that they receive the assistance necessary from staff. Residents stated that they will request assistance to meet their needs by asking staff available at the front desk, or whoever is on duty during the day or night. Nine residents reported that they have a social worker who they see regularly two times a month, or as needed. Nine residents reported that they have a psychologist or psychiatrist they see regularly. One resident reported that they are aware that a psychologist is present at the facility all the time, every day. Staff interviewed reported that the facility has a psychiatrist present at the facility two times a month, and provides individual therapy sessions to residents who do not have an outside provider. Additionally, there are two psychologists available once a week for residents who have either Medical or Medicare benefits and who do not have an outside provider. Based on the interviews and answers by residents and staff, and the records review, this allegation is found to be Unsubstantiated at this time.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20200507140728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GILMAR MANOR	FACILITY NUMBER: 197603675
	VISIT DATE: 12/01/2021

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
26
27
28
29
30
31
32

Regarding the allegation: Failure to provide adequate supervision. It is alleged that clients and residents are mistreating other residents. LPA Urena interviewed 11 residents about the supervision provided by staff at the facility and the overall climate and safety of the residents at the facility. Ten residents reported that the residents are civil and nice with each other for the most part. Residents stated that if residents have differences between themselves and they cannot resolve them, the facility staff are called to assist. Three residents stated that residents are friendly all the time. Ten residents stated that they feel safe at the facility and can count on staff to intervene if residents have differences with other residents. Residents stated that if differences arise between roommates and if roommates cannot come to an agreement, then staff make arrangements to have the residents moved and have different roommates. One resident stated that the facility staff are pretty good at pairing residents as roommates. Eleven residents stated that they feel safe at the facility. Staff interviewed stated that when residents have issues, they assist them to try to resolve their issues. Based on the interviews and answers by residents and staff, this allegation is found to be Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted with Johana Chavez, Office Manager. Signatures obtained. A copy of report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3