198603136-10-15-2020-28-AS-MVAO-BXPNY8-20210128095220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/15/2020
Date Signed: 10/15/2020 04:11:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201007105529

FACILITY NAME:	LE BLEU CHATEAU		FACILITY NUMBER:	198603136
ADMINISTRATOR:	SOKOLOWSKI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1900 GRISMER AVE		TELEPHONE:	(818) 843-3141
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 76	DATE:	10/15/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Michael Sokolowski, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not safeguard resident's money.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Michael Sokolowski.

The investigation consisted of the following: Residents (R1- R9), staff (S1- S4), and Hospice agency staff were interviewed. Resident (R1's) documents were requested/obtained: Identification and Emergency Information (Face Sheet), Authorization Agreement for Pre-Authorized Payments [dated 2/28/20], Physician Report, Preplacement Appraisal, Admission Agreement, Hospice Plan of Care, Personal Rights, Resident Personal Property and Valuables, LIC 500 Personnel Report, list of resident with direct debit services, and resident roster.

See LIC 9099C for continuation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

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 28-AS-20201007105529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LE BLEU CHATEAU	FACILITY NUMBER: 198603136
	VISIT DATE: 10/15/2020

NARRATIVE

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Allegation: "Staff did not safeguard resident's money." Based on document review, information gathered, and interviews conducted the findings revealed that resident (R1) agreed to, and signed an "Authorization Agreement for Pre-Authorized Payments" on 2/28/2020 upon moving in to the facility. Resident (R1) did not recollect signing the authorization agreement, and stated that the direct debit service was not explained. Resident (R1's) file documents were reviewed. Dementia and macular degeneration were noted. Hospice agency staff reported episodes of forgetfulness. During today's interview, R1 was oriented to time and place, but admitted to not remembering if authorization was signed. Resident would like to terminate the authority to initiate debit entries for the purpose of monthly rent payments. A total of nine (9) residents were interviewed; none reported unauthorized direct debit service withdrawals from their personal bank account, or knowledge of financial abuse. A total of (4) residents are enrolled in direct debiting for rent monies; all acknowledged consent.

Per staff interviews, a third party company provides resident fund accounting system for the facility. Direct debit service for the payment of monthly rent fees is provided as an option to residents. Residents must sign service authorization in order to be enrolled. The authorization could be revoke at any time in writing. Only facility management staff have access to the database. Administrator Michael Sokolowski stated there have not been any reports of mis-use of resident monies. Administrator reported that due to COVID-19 stay at home orders, management staff sometimes get resident requests, i.e. purchase of cigarettes or other personal items with the resident's ATM cards. According Administrator, the ATM PIN number is not obtained, and all purchases are made via ATM credit function. All staff denied allegation. Documents obtained confirm the direct debit withdrawals were authorized by resident (R1).

Based upon document review and interviews conducted the findings indicate that, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

A telephonic exit interview was conducted with Administrator Michael Sokolowski. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2020

LIC9099 (FAS) - (06/04)

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