197607495-4-3-2024-29-AS-DPEA-D5PM95-20240528092411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607495
Report Date: 04/02/2024
Date Signed: 04/03/2024 08:14:23 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
03/25/2024 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20240325154909

FACILITY NAME:	CHATEAU LE PETITE III		FACILITY NUMBER:	197607495
ADMINISTRATOR:	BELINDA DOLINSKY		FACILITY TYPE:	740
ADDRESS:	24312 CARIS STREET		TELEPHONE:	(818) 610-1082
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	04/02/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Dion Dexter Olavario		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not allow resident to have a personal caregiver

Resident has unexplained bruising due to being mishandle by staff

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility to conduct an initial 10-day complaint visit. Upon arrival, LPA was greeted by House Lead Dexter Olavario who contacted Administrator Belinda Dolinsky via phone. Administrator was unable to be present at this time; however, authorized lead staff Olavario to continue with investigation and to sign report at the end of the visit.

At 10:30 a.m., LPA Conway conducted a physical plant tour, reviewed facility documents included but not limited to personnel schedule, residents’ roster and hospice files. Also, at 11:06 a.m., LPA conducted interviews with staff, residents, and family members.

Continued on LIC 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 2

Control Number 29-AS-20240325154909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
	VISIT DATE: 04/02/2024

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

Continued from LIC 9099

It was reported that Resident #1 (R1) has unexplained bruising due to staff mishandling R1. Interviews conducted with R1’s family reflected that they visit the facility often and staff are friendly, dedicated and provide the residents with the care and assistance they require. R1’s family further stated that they have never observed R1 mistreated or handled in a rough manner by facility staff. Interviews and records reviewed further reflected that R1 tends to bruise easily due to R1’s health issues and underlying conditions. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident has unexplained bruising due to being mishandle by staff” is deemed UNSUBSTANTIATED at this time.

It was further alleged that the facility staff did not allow resident to have a visitor, as R1’s private companion was not allowed to visit R1. Interviews conducted during the course of the investigation reflected that R1’s family and friends often visit the facility and that no visitors were ever denied visitation. Families are allowed to stay later, and some visitors are also able to make arrangements to come after visiting hours, if necessary. Staff denied every refusing anyone entry to visit a resident. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff did not allow resident to have a personal caregiver” is deemed UNSUBSTANTIATED at this time

Exit interview, appeals rights provided. A copy report given to lead staff.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2