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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603675
Report Date: 02/03/2023
Date Signed: 02/03/2023 04:15:14 PM

Document Has Been Signed on 02/03/2023 04:15 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gabriela Chavez - Assistant AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with Assistant Administrator Gabriela Chavez and explained the reason for the visit.

LPA toured 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. Fire extinguishers throughout the facility were observed to be fully charged and last serviced April 2022.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional at this time. LPA found a sufficient amount of perishable food stored in the fridge and non-perishable food  properly stored. The supply of dishes, utensils, pots, pans and drink ware is adequate.  The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F.  There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional.  Trash cans had tight fitting lids. Additional non-perishable foods and emergency food supply were observed to be properly stored in a storage closet on the second floor. Kitchen was inaccessible to clients at this time.

Bedrooms:  LPA inspected (7) randomly selected bedrooms.   All bedrooms for clients use were properly furnished and had appropriate bedding and linens. At approximately 1:30pm, LPA observed staff cleaning common areas and resident bedrooms.

Bathrooms:  All bathrooms inspected  appeared to be   clean, properly supplied and had functional fixtures. The hot water temperature tested in the bathrooms was observed to be within the range of 110 - 115 degrees Fahrenheit
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GILMAR MANOR
FACILITY NUMBER: 197603675
VISIT DATE: 02/03/2023
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Continued from 809

Common Areas:  These included  dining areas, activity room and patio. The common areas were properly furnished and relatively clean. At  approx 01:45pm, LPA observed multiple clients watching television in the dining area. There was a communal staff fridge and (2) vending machines located in this area. LPA observed  signs to wipe down each appliance  after each use and sanitizer readily available nearby. There was a basement located near the kitchen entrance. LPA observed this area to store extra PPE supplies, building materials  as well as the electrical storage closet.  LPA observed (3) laundry rooms (2) on the second floor and (1) on the first floor. Laundry room on the 2nd  was designated for clients use. LPA observed  laundry room and staff laundry room  to be clean and fixtures appeared to be functional at this time.   Emergency/disaster and  PPE supplies are properly stored in several areas easily accessible to staff.

Surrounding Grounds: The covered parking area is attached to the facility. LPA did not observed and hazardous items or material in this area during the visit. LPA observed  courtyard leading into parking area equipped with patio furniture appropriate for outdoor use and plenty of room for outdoor activities. There is also a front patio at facility entrance equipped with patio furniture appropriate for outdoor use as well. LPA did not observe any obstructions to emergency exits at this time and there were no bodies of water on the premises.

INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate (1) of (4) vacant units as the  single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted and report issued to Assistant Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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