198603136-10-13-2022-28-AS-MVAO-CKDSVT-20221020141315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/13/2022
Date Signed: 10/13/2022 10:48:33 AM

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
01/04/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210104085209

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: 99	DATE:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Staff #1: Marili Barrajas, Office Manager		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident contracted infections while in care resulting in hospitalization.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Marili Barajas, Office Manager). LPA/RA Ceniceros spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 01/13/21 (via telephone) with S1 due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 8:15 a.m. - 9:00 a.m.) facility staff member and residents in care (R2-R3). Resident #1 was not interviewed; as the resident moved out of the facility on 12/29/20. LPA/RA Ceniceros reviewed pertinent documents (between 9:00 a.m. – 9:45 a.m.): Admissions Agreement, Emergency I.D. & Info, Physician’s Report, Pre-placement Appraisal Information, Power of Attorney Advance Health Care Directive, Resident Departure form for Resident #1; and facility staff roster and residents' roster.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 2

Control Number 28-AS-20210104085209

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: 10/13/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation #1: this investigation revealed based on interviews conducted of facility staff and residents in care (R2-R6) corroborated that the facility conducted proper COVID testing to keep their residents safe from contracting COVID during the first year; however, Resident #1 was never diagnosed with COVID. Residents and Staff are tested twice a week for COVID to date. LPA/RA Ceniceros reviewed Resident #1's "Physician Report" (dated 09/25/20). A review of Resident #1's "Pre-placement Appraisal Information" form (dated 11/21/20) was completed and signed by Resident #1's Power of Attorney for Advance Health Care Directive documented under "Health History" (dated 11/21/20) documented: "UTI Infections" prior to Resident #1 being admitted to the facility on 12/01/20. Resident #1 moved out of the facility on 12/29/20 due to hospitalization for a diagnosis that the resident had once transferred from a skilled-nursing facility to the assisted-living facility on 12/01/20.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident contracted infections while in care resulting in hospitalization is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the Complaint Report provided to Staff #1: Marili Barrajas, Office Manager.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2