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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603675
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:01:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/05/2025 01:01 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GILMAR MANORFACILITY NUMBER:
197603675
ADMINISTRATOR/
DIRECTOR:		VLADIMIR CHERTOKFACILITY TYPE:
735
ADDRESS:15152 VICTORY BLVD.TELEPHONE:
(818) 989-2651
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 78CENSUS: DATE:
03/05/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Gabriella ChavezTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 11:07 AM. LPA met with facility staff who contacted the facility’s Assistant Administrator Gabriella Chavez. The Assistant Administrator arrived to the facility at approximately 11:10 AM, entrance interview conducted and the reason for the visit was explained. The following was observed.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the


facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The infection control plan is reviewed/updated annually by the facility’s Administrator. Emergency disaster drills are conducted monthly; the facility’s last emergency disaster drill was conducted on 02/07/2025. LPA observed the facility to be utilizing an out-of-date LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly. LPA informed the Assistant Administrator that the form was out of date and that the facility should be utilizing an LIC 610D, Emergency Disaster Plan For Adult Community Care Facilities and Residential Care Facilities For The Chronically Ill, as the facility is licensed as an Adult Residential Facility (ARF). The Assistant Administrator stated that they are aware and the facility is currently working on completing an updated LIC 610D. The Assistant Administrator stated that they would send a copy to CCLD once it is completed.

MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GILMAR MANOR
FACILITY NUMBER: 197603675
VISIT DATE: 03/05/2025
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INTERVIEWS: LPA interviewed five (5) staff members. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During the 02/28/2025 visit LPA obtained a copy of the facility’s LIC 500, resident roster, liability insurance, and commercial property insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2025 01:01 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/05/2025 at 12:39 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GILMAR MANOR
FACILITY NUMBER: 197603675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
80023(a)

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80023 Disaster and Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.
This requirement is not met as evidenced by:
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Licensee will submit proof of a completed and up to date emergency disaster plan to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as the facility was utilizing an out-of-date LIC 610E emergency disaster plan which poses a potential safety risk to clients 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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