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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/01/2021
Date Signed: 10/01/2021 02:52:40 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
12/26/2019 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191226095848
FACILITY NAME:LE BLEU CHATEAUFACILITY NUMBER:
198603136
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-0411
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 70DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marili Barajas (House Manager)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff not providing residents medication in a timely manner.
Staff failed to keep an accurate medication log.
Staff failing to provide adequate food service.
Staff failed to meet residents dietary needs.
Staff failed to keep facility clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to this facility. The purpose of the visit was to gather information regarding the allegations and to complete the investigation. LPA met with Marili Barajas (House Manager) and explained the reason for the visit.

During the initial visit conducted on 01/03/20, LPA obtained/reviewed a copy of the Staff/Resident roster, medication logs for Resident #1 through #7, interviewed Staff #1 in the staff dining room at 9:46 am, toured the facility at 11:03 am with Staff #1 and interviewed Resident #1 through #4 in the staff dining room between 11:28 am to 1:54 pm.

During today's visit, LPA obtained a copy of the Staff schedule, Resident roster and food menu. LPA interviewed Resident #5 to #9 between 10:20 am to 11:30 am in the conference room, interviewed Staff #2 in the conference room at 11: 35 am and took a tour of the facility with Staff #2 at 11:45 am and interviewed Staff #3, #4, #5 and #6 in the conference room between 11:50 am to 1:00 pm. Continue to LIC9099C......
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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 28-AS-20191226095848
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: 10/01/2021
NARRATIVE
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In regards to the allegation: Staff not providing residents medication in a timely manner. Interviews with Residents and Staff indicate that medications are provided on a timely manner. Review of medication record also indicate medications are provided on a timely manner.

In regards to the allegation: Staff failed to keep an accurate medication log. LPA reviewed medications logs for Residents #1 to #7 revealing medications are accurately documented. Interviews with Staff indicate medications are accurately documented each time assistance with medication administration is completed.

In regards to the allegation: Staff failing to provide adequate food service. LPA's interviews with Resident indicate that food service is adequate. Facility provided breakfast, lunch and dinner to Resident with snacks in between. LPA toured the kitchen and reviewed the food menu which indicate there is sufficient food supplies and foods are of good quality. Interviews with Staff also indicate Residents with certain dietary needs are provided food based on their modified diets.

In regards to the allegation: Staff failed to keep facility clean. During the initial visit, LPA toured the facility and observed parts of the facility was being renovated. During the today's visit, LPA toured the facility again and observed the facility to be clean and in good repair. Interviews with Staff and Resident indicate that facility is clean. Facility renovations occurred in late 2019. Interviews with Staff and Resident indicate that proper notices were provided to Resident and Staff prior to the start of renovations and Residents and Staff were aware the facility will inevitably experience dust and debris.

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

Exit interview conducted with Marili Barajas and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
12/26/2019 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20191226095848

FACILITY NAME:LE BLEU CHATEAUFACILITY NUMBER:
198603136
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-0411
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 70DATE:
10/01/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marili Barajas (House Manager)TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff not answering call buttons in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to this facility. The purpose of the visit was to gather information regarding the allegations and to complete the investigation. LPA met with Marili Barajas (House Manager) and explained the reason for the visit.

During the initial visit conducted on 01/03/20, LPA obtained/reviewed a copy of the Staff/Resident roster, medication logs for Resident #1 through #7, interviewed Staff #1 in the staff dining room at 9:46 am, toured the facility at 11:03 am with Staff #1 and interviewed Resident #1 through #4 in the staff dining room between 11:28 am to 1:54 pm.

During today's visit, LPA obtained a copy of the Staff schedule, Resident roster and food menu. LPA interviewed Resident #5 to #9 between 10:20 am to 11:30 am in the conference room, interviewed Staff #2 in the conference room at 11: 35 am and took a tour of the facility with Staff #2 at 11:45 am and interviewed Staff #3, #4, #5 and #6 in the conference room between 11:50 am to 1:00 pm. Continue to LIC9099C......
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20191226095848
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: 10/01/2021
NARRATIVE
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In regards to the allegation: Staff not answering call buttons in a timely manner. Interviews with Residents and Staff indicate there were incidents which Staff did not response to Resident's call switch in a timely manner.

Based on LPA's interviews, investigation revealed that the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Marili Barajas and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20191226095848
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2021
Section Cited
CCR
87415(a)(2)
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87415(a)(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.
This requirement is not met as evidenced by:
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Licensee shall provide a plan to meet sufficient staffing and provide proof of sufficient staffing to the department by the POC date.
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Interviews with Residents and Staff indicate there were incidents which Staff did not response to Resident call switch in a timely manner.
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NOTE: LPA's review Staff schedule during visit and observed that facility now has sufficient day and night staffing.
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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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5