198603136-8-25-2021-28-AS-LHIS-C72TSK-20210920145916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:19:21 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
07/30/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210730123119

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: 72	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator, William Boles		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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A residents wheelchair was damaged while in care
Staff did not provide necessary accommodations for a resident in care
Staff are not providing resident with all medical records/incident reports
Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Administrator, William Boles who assisted with today's visit.

Regarding the allegation that a former residents wheelchair was damaged while in care and staff did not provide necessary accomodations for resident in care, the investigation consisted of interviews with Administrator, Staff #1 and Resident #1 - Resident #6. Administrator and Staff #1 stated that they were not aware that former resident's wheelchair was damaged while in care. They stated that it was not brought to their attention. Administrator and Staff #1 stated that staff do provide necessary accomodations for residents in care. LPA interviewed 6 Residents who use wheelchair(s). 5 out of 6 residents stated that they have no trouble with the accomodations provided, and have no trouble maneuvering their wheelchair(s) at the facilty. 6 out of 6 residents stated that their wheelchair has not been damaged while in care.

LPA toured the facility and observed that the facility hallways, resident rooms, and bathrooms are able to accommodate residents who use a wheelchair.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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-20210730123119

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: 08/25/2021

NARRATIVE

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Regarding the allegation that Staff are not providing former resident with all medical records/ incident reports. LPA interviewed Administrator and Staff #1. Administrator and Staff #1 stated that facility has not refused to provide medical records and incident reports to former resident. Staff #1 stated that she has spoken to former resident and is going to arrange for former resident to obtain copies of the records/ reports that are being requested.

Regarding the allegation that Staff did not safeguard resident's personal belongings, the investigation consisted of interviews with Administrator, Staff #1 and Resident #1 - Resident #6. Administrator stated that he was not aware of any incident regarding former residents personal belongings not being safeguarded. Staff #1 stated that former resident asked a staff person to purchase items for her. Staff #1 stated that a staff person purchased items and returned the change to Former resident. Staff #1 denied that former residents belongings were not safeguarded. Residents interviewed were unable to corroborate the allegation. They stated that their personal belongings are safeguarded at the facility.

Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview conducted and copy of report was provided to Administrator.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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