198603136-11-13-2020-28-AS-MVAO-BXURRE-20210202121501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 11/12/2020
Date Signed: 11/13/2020 04:44:01 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
11/06/2020 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201106101259

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: 77	DATE:	11/12/2020
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Michael Sokolowski		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

illegal eviction

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Cynthia Chan 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 Michael Sokolowski, the facility administrator.

LPA Chan conducted telephone interviews with the Administrator, Office Manager, and the Marketing Director. LPA also obtained the staff and resident rosters, Resident #1's Emergency Identification form, Physician's Report, Admission Agreement, and PrePlacement Appraisal form.

Based on documents reviewed and interviews, resident #1 (R1) does not reside at this facility but at the sister facility Le Bleu Chateu - Gold #198603137. Per Administrator, R1 was admitted to the hospital and has not returned. It is determined that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
An exit interview was conducted with the Administrator. This report was sent via email for a signature and appeal rights were also provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020

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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