198603136-9-1-2022-28-AS-RORN-CK5UY9-20221012155932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:48:08 PM

Unsubstantiated

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
08/18/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210818102537

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: 96	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Nirjara Acharya		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care
Staff handled resident in a rough manner
Staff failed to treat residents with dignity and respect
Staff made inappropriate comments toward resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made a subsequent visit for the allegations listed above. LPA met with Office Manger Marili Barajas and Administrator Nirjara Acharya.
At initial visit 08/19/2021 the following occurred:
The investigation consisted of the following: Interviews with Administrator, and Staff S1-S 3 from 9:15 AM to 11:00 AM. LPA Trueman requested Physician's Report, Needs and Services Plan, Emergency ID page and Hospice Documentation from Resident 1's file.
At today's visit 09/01/2022 from 1:15 PM to 3:00 PM Resident's 1-8 were interviewed.
In regards to Resident sustained pressure injuries while in care, Documentation from Hospice Agency for Resident R1 specifies Physician's Order start date 08/10/2021 and stop date 09/08/2021 L ankle wound and to cleanse with NS pat dry and cover with gauze every 2 to 3 days as needed.
Documentation titled Skin Impairment Assessment from Hospice Agency dated 09/09/2021 stated that R1 has existing treatment for left ankle wound.
Staff interviewed stated that R 1 was on Hospice who were addressing wound care. Staff would try to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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-20210818102537

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: 09/01/2022

NARRATIVE

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soothe R 1 by putting pillow under feet.
Interview with residents revealed that R3 had wound on leg and it is handled well. R 8 has had a wound
on the back and it has been handled great 2x a week.
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.
In regards to the allegation Staff handled resident in a rough manner, based on interviews conducted and information gathered interviews with R5, R6, R7 and R9 all have had diaper changes and stated that staff have never handled them roughly and always do a great job.
R2, R3 R4 and R8 stated they had never been handled roughly when needing any kind of assistance.
Interview with staff who stated that R1 is showered by Hospice who handles her gently and that when diaper is changed staff will never be rough.
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.
In regards to the allegation Staff failed to treat residents with dignity and respect, based on interviews conducted and information gathered R2-R 9 stated that they have always been treated with dignity and respect and that staff have never acted inappropriately.
Staff interviewed stated that they had never been disrespectful to R1 or to any residents.
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.
In regards to the allegation Staff made inappropriate comments toward resident, this allegation was previously addressed based on visit conducted on 06/02/2021 Complaint # 28-AS-20210525114334 Substantiated Findings and 9099 D page issued stating that S1 yells at residents and 9099 addressing allegation of inappropriate comments. Interview with Administrator 08/19/2021 who stated that S1 had been terminated.

It should be noted that R1 had left on 9/11/2021 to St. Joseph Hospital and was discharged on 09/17/2021 from the facility.
Attempts to contact R1 were unsuccessful.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

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