198603136-4-21-2021-28-AS-MVAO-C74PFQ-20210922111707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 04/18/2021
Date Signed: 04/21/2021 05:47:58 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
04/02/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210402103825

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: 64	DATE:	04/18/2021
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	William Boles, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility has bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint visit for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with William Boles, Administrator.

The investigation consisted of the following: On 04/08/21, LPA Almaraz interviewed Administrator, Staff #1-2 and Residents #1-7 and attempted to interview Resident #8 but resident was at a medical appointment. LPA requested resident files for Resident #4 and #6, Staff and Resident Roster and Pest Control Records. On 4/14/21, LPA interviewed Staff #3-4 and requested additional Pest Control documents.

The investigation revealed the following: Based on interviews conducted and records reviewed, the facility has had a pest control issue in some of the residents rooms. (Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021

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 5

Control Number 28-AS-20210402103825

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: 04/18/2021

NARRATIVE

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Records provided indicate they facility had Orkin Services of California Inc. go out to the facility and treat some rooms around 1/29/21 with the last service dated on 3/3/21.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature. Appeal Rights was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210402103825

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: 04/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/18/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility will ensure they have a contract through Orkin Pest Control for a "Cockroach/Rodent Program" where the exterminator visits the facility monthly for inspections/treatments in order to eradicate the pest problem. Administrator will ensure that a visual inspection is conducted in ALL the reisdent
	8 9 10 11 12 13 14	During the course of this investigation, it revealed through interviews and records reviewed the facility has german roaches and bed bugs in the facility. LPA discovered that an exterminator treats only rooms 225, 102, 230 and 217 in the facility.	8 9 10 11 12 13 14	bedrooms and the infested rooms will be immediately treated. A report of all the rooms treated and A PLAN OF ACTION will be also submitted to CCLD documenting how the facility will ensure that all resident rooms and common areas are free from pest issues by POC due date.
	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/02/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210402103825

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: 64	DATE:	04/18/2021
		UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	William Boles, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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5
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7
8
9

Staff not treating resident with dignity and respect.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint visit for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with William Boles, Administrator.

The investigation consisted of the following: On 04/08/21, LPA Almaraz interviewed Administrator, Staff #1-2 and Residents #1-7 and attempted to interview Resident #8 but resident was at a medical appointment. LPA requested resident files for Resident #4 and #6, Staff and Resident Roster. On 4/14/21, LPA interviewed Staff #3-4.

The investigation revealed the following: Based on interviews conducted with residents all staff treat the residents with dignity and respect. (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210402103825

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: 04/18/2021

NARRATIVE

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Staff interviews conducted revealed that they have not heard anyone speak or treat any of the residents disrespectful or in a undignified manner. Staff and management indicated some residents are impatient when they want something but they have not complained about being mistreated. Six out seven residents indicated they have no complaints regarding staff.

Although the allegations 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 is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Administrator and a hardcopy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5