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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603675
Report Date: 09/16/2022
Date Signed: 09/17/2022 09:49:04 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
11/30/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20201130152308
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):
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Staff yells at the residents
INVESTIGATION FINDINGS:
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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 11/30/2020, the Department received a complaint regarding staff yelling at the residents. On 12/08/2020, 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 interviews, 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 5
Control Number 29-AS-20201130152308
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
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During Staff #1 (S1) interview on 12/08/2020, it was revealed that Client #1 (C1) approached S1 and made statement that they were afraid. C1 added that staff members and clients make C1 feel very stressed. C1 told S1 that S2 was one of those persons. S1 told LPA Miller that S1 had witnessed an incident between S2 and C1. S1 continued, S2 did raise their voice and yelled at C1. Other clients have complained about S2 yelling at them in the past. S1 added that C1 came to S1 because S1 had witnessed the incident. S1 stated that there was an issue with a prescription for C1. S1 continues, C1 gets very stressed and flustered when dealing with confrontational situations. It's very difficult to calm C1 down once upset. S2 began yelling at C1 telling them to stop whining and they threaten to send the medication back to the pharmacy. S1 also added that they had observed S2 telling other clients if they show up late for their meals, they would not be able to receive their meals. Interview with C1 on 09/16/2022, starting at 01:27 p.m., revealed that C1 has various prescription drugs that they need to take. One drug needed refills but S2 had not called it in to the doctors. C1 became upset requesting S2 to call for the refill. C1 wanted the medication but S2 yelled at C1 that the “medication was on its way”, “stop bugging me, don’t bug me again” and “ I’ve told you already, I am not dealing with you.”

Based on interviews, the allegation staff yells at residents, 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 the report and appeal rights provided to Admin 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: 2 of 5
Control Number 29-AS-20201130152308
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 A
09/19/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Right (a) (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Admin stated they will conduct facility staff training on Personal Rights. Admin will provide LPA copy of training material and attendees of the training. Admin will submit the documentation to LPA via email.
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Based on interviews, the licensee did not comply with the section cited above as the S2 yelled at C1 which poses a potential health, safety and personal rights risk to persons 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.
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 5
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
11/30/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20201130152308

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
Residents medications not being provided in a timely manner.
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 11/30/2020, the Department received a complaint regarding resident’s medication not being provided in a timely manner. On 12/08/2020, 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
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 5
Control Number 29-AS-20201130152308
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
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On 09/09/2022, LPA Ascencio conducted staff interviews, starting at 11:15 a.m. Staff interviews revealed that medication is kept in the front office, locked at all times. The medication has been labeled for each individual in the facility. The clients will come down from their room and request their medication. Staff will observe the clients taking their medication. If a client forgets to show up, staff use the Public Announcement System (PA), which can be heard through the facility, to call the clients name and remind them to come down to pick up their medication. Further staff interviews revealed that, if a client is going to leave for an extended amount of time, the facility will provide the client with the medication needed. Later that same day, starting at 11:45 a.m., six (6) out of 72 client interviews revealed that medication is always given by the staff person in charge at the front desk. Clients also added that there hasn’t been a problem with missed medication, medication being late, or medication missing. LPA Ascencio conducted a Medication Administration Record (MAR) review on seven (7) out of 72 clients. During the MAR review, LPA did not observe any missed medication or missing signatures on the MAR. Based on record review and interviews, the allegation of residents medication not being provided in a timely manor is deemed UNSUBSTANTIATED at this time.


Exit interview conducted and copy of the report provided to admin 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: 5 of 5