198603136-12-1-2022-28-AS-MVAO-CLUUEU-20221206143140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:03:54 PM

Substantiated

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
07/23/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200723145406

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:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Nirjana Acharya, Administrator		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has bed bugs.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation for the allegations listed above. The purpose of the visit was explained to Office Manager Marili Barajas. Administrator Nirjana Acharya arrived shortly after and assisted with today's visit.
The investigation consisted of the following: On 7/29/20, due to COVID-19 pandemic a virtual physical plant inspection of resident rooms was conducted via FaceTime between 3:07 pm – 3:49 pm. LPA observed rooms 102, 115, 123, 124, 125, 203, 215, 216, 220, and 245. Staff (S1- S3), and residents (R1- R2) were interviewed. On 8/12/2020, LPA interviewed residents (R3-R10) and staff (S4-S6) telephonically, and visually inspected rooms 217, 218, 220, & 221 via FaceTime. 8/13/2020. The following documents were obtained: Identification and Emergency Information/Face Sheet, Admission Record, physician order (7/20/20), POLST, Preplacement Appraisal Information, Admission Agreement, Shower Assignment, and MD Visit report. During today's visit, a physical plant inspection of the facility common areas and resident rooms was inspected, and staff (S7-S10) were interviewed. Pending documents [shower logs, pest control invoices, rosters, and Physician Report] were obtained.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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 3

Control Number 28-AS-20200723145406

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: 12/01/2022

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

Allegation: Facility has bed bugs. It is alleged that resident (R1) was asked to isolate in it's room filled with bed bugs, but was not moved to another room immediately; and staff did not clean the room after they were made aware of the bed bug problem. Per staff interviews, the resident was not isolated in it's due to bed bugs, but rather was quarantined in the room per physician order due to possible shingles. Based on record review and interviews conducted the findings indicate the facility had bed bugs between June 2020 - October 2020. The majority of the bed bug infested rooms were on the 2nd floor, but at least one room on the 1st floor also received bed bug heat treatment by Round The Clock Pest Control, Inc. Administration staff ordered chemical treatment of the rooms, and brought in a dog to detect bed bugs. Pest control records and staff interviews confirmed that the facility had bed bugs, and R1's room was one of the rooms that received bed bug heat treatment. Two (2) out of 10 residents stated their rooms had bed bugs and were heat treated by pest control. Staff confirmed the facility had bed bugs at that time.

Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Administrator Nirjana Acharya. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200723145406

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: 12/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/15/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agrees to: 1. Maintain a contract with a licensed pest control extermination company for bed bugs. 2. Provide a written plan to CCL that addresses prevention/treatment of bed bugs 3. Inspect all rooms for cleanliness. 4. Provide training to all staff. 5. Submit training topic and staff attendance log to CCL.
	8 9 10 11 12 13 14	Based on interviews conducted, pest control document review, and physical plant inspection the facility had bed bugs beginning in June 2020- through at least Oct. 2020. This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3