197603675-5-17-2022-29-AS-DPEA-CETVPL-20220527163656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603675
Report Date: 05/17/2022
Date Signed: 05/17/2022 03:39:44 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
11/10/2021 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20211110094811

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: 70	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	02:31 PM
MET WITH:	Gabriella Chavez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff rough handled Resident #1 (R1) resulting in multple bruises.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegation. The initial visit was conducted by LPA on 11/10/2021. During today’s visit, LPA met with Gabriella Chavez and explained the reason for the visit.

On 11/10/2021, the Department received a complaint alleging that facility staff attempted to drown Resident #1 (R1) in R1’s bathtub, which resulted in multiple bruises. During the initial visit, LPA met with Assistant Administrator Gabriella Chavez and explained the reason for the visit. Between 1:30pm – 3:30pm, LPA conducted a tour of the physical plant, and also conducted interviews with facility residents and staff. Additionally, LPA reviewed and obtained copies of pertinent documentation relevant to the investigation.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211110094811

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: 05/17/2022

NARRATIVE

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(Continued from 9099)

On 3/25/2022, at approx. 4:30 p.m., LPA interviewed Staff #1 (S1) who worked the evening shift of the alleged incident. On 3/28/2022, at approx. 5 p.m., LPA interviewed Staff #2 (S2) and Staff #3 (S3), who also worked during the evening shift of the alleged incident. On 04/11/2022, LPA interviewed a family member of R1. Moreover, on 4/12/2022, 4/13/2022, 4/15/2022 and 4/20/2022, LPA attempted to conduct additional interviews with R1 and parties relevant to the investigation; however, was not successful. On 4/27/2022, LPA reviewed R1’s hospital records from Los Angeles Community Hospital at Bellflower and Valley Presbyterian Hospital.

Information gathered revealed that on 09/03/2021, at approximately 8:30 p.m., R1 returned to the facility from the hospital via emergency transport and was escorted to R1’s room. Per interviews, shortly after, R1 came out from R1’s room dressed in the hospital gown and appeared to be a bit agitated. Per interviews conducted, R1 was not demonstrating R1’s typical behavior. R1 threw a 5-Gallon water dispenser on the floor, which caused most of the water to spill out. R1 was redirected back to the room, and S1 assisted R1 in getting dressed. R1 then proceeded to enter bathtub, sit-down and turn on the water. S1, S2 and S3 observed the bathtub drain to be open and the water continued to run into the drain. S2 then called 911 and R1 was transported back to the hospital. Interviews conducted with R1’s roommate, and other staff revealed that no one witnessed staff trying to drown R1 in the bathtub, or anything physical which would cause bruising to R1.

Furthermore, interview conducted with R1s family revealed that they had no concerns for the health and safety of R1 while R1 was residing at the facility. The family also stated that they have not witnessed staff rough handling R1 which would cause any bruising. Hospital records reviewed revealed that there was no evidence of bruising to R1 upon admission to the hospital. Per hospital records reviewed, R1 was admitted to the hospital for acute encephalopathy, psychosis versus toxic metabolic from possible Urinary Tract Infection (UTI) and suicidal attempt. Based on information gathered, the Department does not have sufficient evidence to determine staff rough handled R1 resulting in multiple bruising. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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