<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603675
Report Date: 09/16/2022
Date Signed: 09/17/2022 09:40:25 AM

Substantiated


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
11/16/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20201116105035
FACILITY NAME:GILMAR MANORFACILITY NUMBER:
197603675
ADMINISTRATOR:VLADIMIR CHERTOKFACILITY TYPE:
735
ADDRESS:15152 VICTORY BLVD.TELEPHONE:
(818) 989-2651
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:78CENSUS: 72DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Gabriela ChavezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Failure to provide food of adequate quality & quantity
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. During today’s visit, LPA Ascencio met with Office Manager Johana Chavez at 09:50 a.m. and explained the reason for the visit. LPA and Office Manager Chavez toured the facility inside and out at 9:53 a.m. Administrator Gabriela Chavez arrived at the facility at 12:00 p.m.

On 11/16/2020, the Department received a complaint regarding an allegation of failure to provide food of adequate quality & quantity. On 11/17/2020, LPA Eva Miller conducted an initial complaint visit via video conference due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and met with the Assistant Administrator. LPA Miller virtually toured the physical plant, conducted an interview with the Assistant Administrator and requested pertinent documents.

Continued on LIC 9099 - C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
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 7
Control Number 29-AS-20201116105035
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: 09/16/2022
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
On 09/09/2022, LPA Ascencio conducted interview with Office Manager Chavez starting at 11:15 a.m. Interview with Office Manager revealed they have a dietitian that comes out to the facility and helps modify the menus for the clients based on their needs. Additional interview with Administrator Gabriela Chavez, starting at 12:26 p.m. revealed that the dietitian conducts client surveys and gets their input on future foods to add to the menu. Admin Chavez continues, the dietitian was here the last week of August and was told that the clients were happy with the choice of foods we have been providing. Admin Chavez also added that if a client does not like the food item being served, the alternatives is a cheese sandwich or bologna sandwich. Additionally, the menu gets rotated every 4 weeks. LPA Ascencio conducted six (6) client interviews out of 72 on 09/09/2022, starting at 11:45 a.m. Client interviews revealed that the quality of food is poor and horrible and has been that way for a long time. The clients stated it isn’t the choice of foods but perhaps the ingredients or the low-quality types of foods being used. Four (4) out of the 6 clients interviewed revealed that they rather eat fast food or buy their own food instead of eating the facility food. Clients also stated they don’t have much choice in variety for diabetics; it is either the main food, or a choice between 2 different types of sandwiches. During facility file review, LPA Ascencio reviewed the menus on 09/09/2022 and again on 09/16/2022 and it revealed that the facility menu is set to rotate every four (4) weeks. The menus include: Hot Dogs, Tuna Sandwiches, Ham Sandwiches, Bologna Sandwiches, and Spaghetti; with each food item being offered in 3 weeks out of the 4 weeks. The only alternative for the meal is a bologna sandwich or cheese sandwich.Based on interviews and record review, the allegation of failure to provide food of adequate quality & quantity is deemed SUBSTANTIATED at this time.
1 citation was issued during today’s visit. The following deficiencies were observed (See
LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California

Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, copy of report and appeal right provided to admin vial email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20201116105035
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
80076(a)(1)
1
2
3
4
5
6
7
80076 Food Services (a)(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served.

1
2
3
4
5
6
7
Admin stated they will consult with the dietitian to provide balance meals based on the recommendation of the USDA. Admin will updated food menus and submit the updated food menu to LPA Ascencio via email by 09/30/2022.
8
9
10
11
12
13
14
Based on interviews and facility file review, the licensee did not comply with the section cited above as the food being provided is not safe and the quality and quantity does not meet the needs of each client which poses a potential health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/16/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20201116105035

FACILITY NAME:GILMAR MANORFACILITY NUMBER:
197603675
ADMINISTRATOR:VLADIMIR CHERTOKFACILITY TYPE:
735
ADDRESS:15152 VICTORY BLVD.TELEPHONE:
(818) 989-2651
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY:78CENSUS: 72DATE:
09/16/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Gabriela ChavezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Failure to provide adequate Care and Supervision.
Failure to keep the facility free of insects
Failure to provide safe, healthful and comfortable accommodations
Failure to ensure residents dignity in their personal relationships with staff and other persons
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. During today’s visit, LPA Ascencio met with Office Manager Johana Chavez at 09:50 a.m. and explained the reason for the visit. LPA and Office Manager Chavez toured the facility inside and out at 9:53 a.m. Administrator Gabriela Chavez arrived at the facility at 12:00 p.m.

On 11/16/2020, the Department received a complaint regarding allegations of neglect/lack of supervision. It was alleged that Resident #1 (R1) and R2 are selling and using illegal drugs on facility premises. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

On 11/17/2020, LPA Eva Miller conducted an initial complaint visit via video conference due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and met with the Assistant Administrator.
Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20201116105035
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: 09/16/2022
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
LPA Miller virtually toured the physical plant, conducted an interview with the Assistant Administrator and requested pertinent documents. The LPA informed the Administrator that the complaint allegations required further investigation and the complaint was referred to the Investigations Branch (IB) for review.

IB Investigator Zertuche conducted interviews with Long Term Care Ombudsman (LTCO) on 01/14/2021, starting at approximately at 12:30 p.m. It was revealed there is no LTCO open investigation regarding this case at this time. On 01/14/2021, starting at approximately at 1:00 p.m., Investigator Zertuche conducted a telephonic interview with the Assistant Administrator. Assistant Administrator stated that R1 and R2 still reside in the facility. It was also revealed R1 has medication related issues and R2 keeps to themselves and does not like being told what to do. Assistant Administrator also added that there has been no drug related issue reported.

On 01/27/2021, Investigator Zertuche conducted interviews with residents starting at approximately 1:30 p.m. Interviews revealed that R1 likes living at the facility and gets along with everyone except for certain staff, who R1 believes spreads rumors accusing R1 of selling drugs at the facility. R1 has denied selling or using illegal drugs, and staff have never found any illegal drugs in R1’s possession. It was also disclosed that R2 has not witnessed drugs at the facility and does not know of anyone selling drugs. Four (4) out of four (4) residents who were interviewed denied any knowledge of illegal drugs being used or sold at the facility.

Investigator Zertuche also conducted a staff interview on 01/27/2021 at approximately 3:15 p.m. with Staff #1 (S1). S1 revealed that there was an incident report made from another staff member regarding R1 selling drugs to another resident. After an internal investigation, the incident could not be proven, and all parties allegedly involved denied that it happened.

Continued on LIC 9099 - C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20201116105035
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: 09/16/2022
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
Facility management stated drug sales and usage are not allowed in the facility and the residents interviewed reported the same. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore the allegation deemed UNSUBSTANTIATED at this time.

Regarding the allegation, failure to keep the facility free of insects. LPA Ascencio conducted staff interviews, starting at 11:00 a.m., on 09/09/2022. Staff interviews revealed that at the beginning of 2022, the facility did have insect in certain rooms of the facility. Since then, the facility bought a 110V DIY Bed Bug Heater in December 2021, to warm up the rooms and kill any insect. Additionally, the facility contracted a fumigating company that comes in two (2) times a month for a maintenance check-up. Later that same day, additional interviews with clients, starting at 11:45 a.m., confirmed that at the beginning of 2022, there was a bed bug infestation, but the facility has taken care of it since. During the facility tour on 09/09/2022, LPA Ascencio observed 6 client bedrooms which were clean, free of pest and odors. LPA received the invoice notices from Rhino Pest Control that states that they have been coming out to the facility starting on June 6th, 2022 for routine maintenance and prevention. Based on interviews, observation and pertinent documents, the allegation, failure to keep the facility free of insects is deemed UNSUBSTANTIATED at this time.

It was also alleged failure to provide safe, healthful and comfortable accommodations. During facility tour on 09/09/2022, LPA observed 6 client’s rooms which were furnished appropriately with clean linen, a bed, a dresser and sufficient lighting. LPA also observed several cameras throughout the facility for additional security measures. Later that day, during 6 client’s interviews, it was revealed that clients feel safe living at the facility.

Continued on LIC 9099 - C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20201116105035
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: 09/16/2022
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
Further interviews revealed they feel comfortable in their homes, the facility makes them feel safe and the facility staff try their hardest to keep all clients happy with their request. Based on interviews and observation, the allegation, failure to provide safe, healthful and comfortable accommodations is deemed UNSUBSTANTIATED at this time.

Lastly, it was also alleged failure to ensure resident dignity in their personal relationships with staff and other persons. On 09/09/2022, LPA Ascencio conducted 6 client interviews starting at 11:45 a.m. Client interviews revealed that clients don’t have a problem with any staff members at the facility. Clients also added that they have privacy among each other and privacy when they have visitors in their rooms. Further client interviews revealed that clients have religious freedoms and are respected by other clients and facility staff members. Based on evidence gathered throughout the course of the investigation, the allegation, failure to ensure resident dignity in their personal relationships with staff and other persons is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of this report was provided to the Administrator via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7