198603136-12-1-2022-28-AS-MVAO-CLUUEV-20221206143141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:05:35 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
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):

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Facility staff are not assisting resident with showering needs.
Facility staff do not allow resident to leave their room.
Facility staff are not keeping the resident's room clean

INVESTIGATION FINDINGS:

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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.

Unsubstantiated

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)

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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

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Allegation: Facility staff are not assisting resident with showering needs. It is alleged that resident (R1) was not being showered at least two times per week in July 2020 by facility staff. According to staff interviews, residents are to be showered two times per week and/or as needed. The resident was enrolled in home health but due to the COVID-19 pandemic home health staff were not providing shower assistance.
A total of 10 residents were interviewed, of which four (4) out of 10 residents stated they were not shower at least two times per week between June 2020- July 2020. A total of 10 staff were interviewed. One (1) staff stated that due to the pandemic staffing shortages caregiver staff were not able to shower their assigned residents, and the evening and weekend shift staff did not assist with showers. Per shower record review, R1's was showered regularly.

Allegation: Facility staff do not allow resident to leave their room. It is alleged that resident (R1) was quarantined in it's room due to bed bugs, and as staff mistreatment for not paying rent. Per staff interviews, resident (R1) was quarantined in it's room as a result of skin irritation. Staff handled the situation as a potential shingles outbreak and requested R1 isolate in it's room. Per MD appraisal it was determined not to be the shingles virus. The resident was treated with cream treatment during it's quarantine. One (1) out of 10 residents stated they were not allowed to leave their room. Staff interviews confirmed R1 was quarantined in it's room as a precautionary infection control measure related to possible shingles diagnosis, and not due to bed bugs in it's room. Staff stated that during bed bug room heat treatment residents are always moved out of the room, and in particular this resident was moved out of it's room when the room was treated.

Allegation: Facility staff are not keeping the resident's room clean. It is alleged that R1's room was not being cleaned, and was only cleaned once between July 19, 2020- July 27, 2020. During these dates, R1's room had bed bugs and allegedly never received steam cleaning/heat treatment nor was it's mattress changed. Nine (9) out of 10 resident interviews stated that their room is cleaned daily and reported no issues with room cleanliness or housekeeping. All staff stated that resident rooms are cleaned everyday by housekeeping staff, and in instances of staff shortages caregivers assume general room clean up i.e. taking trash out and cleaning of floors. Staff stated that resident rooms are especially cleaned after bed bug treatment. Housekeeping daily responsibilities are mopping room floors daily, making resident's beds, and cleaning the bathrooms. On days, that housekeeping staff are off other housekeepers are responsible for the tasks.

The findings indicate that 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. Exit interview and a copy of the report was issued to Administrator Nirjana Acharya.

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)

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