197603675-12-1-2021-29-AS-JAPL-C9NV99-20211213151357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603675
Report Date: 12/01/2021
Date Signed: 12/01/2021 08:05:27 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
06/02/2020 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20200602161714

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 ensure each client receives 3 meals per day.
Failure to provide necessary supplies for personal care.
Failure to provide necessary services to clients in care.

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 06/09/2020, Licensing Program Analyst (LPA) Eva Miller initiated a complaint investigation for the allegations listed above. The complaint investigation was conducted via FaceTime with Vladimir Chertok, the facility Administrator. The complainant alleged that direct care staff receive orders from supervisors/managers to withhold breakfast from clients who sleep late. Facility staff refuse to provide bedding/linens to clients upon request. Clients are made to wait unnecessarily for assistance with self-administered medications.

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-20200602161714

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 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 laundry rooms were found to have washers and dryers in operable condition.

The LPA reviewed staff and resident files and found the files to be in order.
LPA Urena conducted residents and staff interviews from 11:00 a.m. to 3:00 p.m.

Regarding the allegation: Failure to ensure each client receives 3 meals per day. Complainant alleged that direct care staff receive orders from supervisors/managers to withhold breakfast from clients who sleep late. LPA Urena interviewed 11 residents, and six staff members. Eleven residents stated that they receive three meals a day, and three snacks. Eleven residents stated that if a meal is missed because they overslept, they can usually ask the staff if there is something available to eat, and for the most part, staff offers the missed meal or fruits, drinks or snacks. Two residents stated that they will go out and buy food for themselves. One resident stated that they like the salads and soups the facility serves every day. Eight residents stated that the meals are pretty good, and the quantity of food is more than enough. Two residents stated that they always get a snack before they get their medication, because some of the meds may irritated their stomach. Staff reported that residents who missed a meal will get something to eat, even if it something else than the meal they missed. One staff reported that they understand the importance of residents being fed. Based on observations and interviews and answers by residents and staff, 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: 3 of 3

Control Number 29-AS-20200602161714

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 necessary supplies for personal care. It is alleged that facility staff refused to provide bedding/linens to clients upon request. LPA Urena interviewed 11 residents, and six staff members. Five residents stated that they have their own linens and personal care items. Five residents stated that they like washing their own clothes and linens. Six residents stated that the staff wash their linens. Ten residents stated that if they need fresh linens, they can request them from the housekeeping staff. Three residents stated that the housekeeping staff is friendly and helpful. Four residents stated that the linens get changed three to four times a week or as needed or requested by residents. LPA Urena observed two laundry rooms on the second floor of the facility with operable washing machines and dryers for the use of residents and staff. Additionally, LPA Urena observed sufficient available linens for residents. Staff reported that housekeeping staff changes the linens, but that some residents decline having their linens changed by staff and prefer doing it themselves. Based on observations and interviews and answers by residents and staff, this allegation is found to be Unsubstantiated at this time.

Regarding the allegation: Failure to provide necessary services to clients in care. It is alleged that clients are made to wait unnecessarily for assistance with self administered medications. LPA Urena interviewed 11 residents, and three staff members. Ten residents stated that all medications are given by staff. The medications are given at specific times of the day on the first floor, according to the doctor’s prescription. Three residents stated that if residents don’t feel well to come to the first floor, then staff bring the medicine to their rooms. Ten residents stated that they receive their medication on time, and when requested. Staff reported that residents receive their medication on the first floor, but if the residents do not show up for the medicine, staff uses the speaker to call the resident, or go to their room to give out the medication to residents in their room. On this visit, LPA Urena observed the process of medication being given to residents. Based on observations, records review, and 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: 2 of 3