198603136-5-20-2021-28-AS-MVAO-C4FQ86-20210629115613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 03/01/2021
Date Signed: 05/20/2021 08:28:25 PM

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
07/15/2020 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200715165238

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: 54	DATE:	03/01/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marili Barajas		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff verbally abuse resident.
Staff threatened resident.
Resident is being financially abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Office Manager Marili Barajas.

The investigation consisted of the following: On 07/23/20, LPA Wesley conducted a telephonic interview and requested copy of: staff roster, resident roster, and specific documents to be faxed/emailed by 07/24/20. LPA Wesley conducted interviews with the Administrator Michael Sokolowski, staff and residents regarding the above mentioned allegations.

Investigation revealed the following: regarding allegations: Staff threatened resident and Staff verbally abuse resident . During the interview with Administrator Sokolowski, he advised that he did not verbally abuse or threaten Resident #1(R1) or witness any staff verbally abuse or threaten (R1). Administrator said that he
Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

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-20200715165238

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: 03/01/2021

NARRATIVE

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informed R1 that they have not paid their rent and are not adhering to the admission agreement that was signed on 04/30/20. The Administrator said that R1 who receives SSI did not wish to pay the monthly rent because they thought they would be in a more clinical type of environment and since they were not receiving the level of care they wanted, they felt the rent should be decreased to $600 a month, which would also allow them to assist their family member with paying some bills. Administrator advised R1 who is also enrolled in the Assisted Living Waiver program, that if they cant pay their monthly rent, they would have to search for another place to reside and since they constantly complained that they are not happy with the services that the facility offers, then they can look for another facility to meet their needs. Administrator said that R1 replied: "I'm from the streets, I'm not scared because I lived on the streets before." During the interview with R1, they said they informed their relative about the incident and said the Administrator threatened them because they mentioned that if they did not pay they would have to issue a 30 day notice, and if they kept leaving the facility, they would have to remain in their room and quarantine for a specific amount of days to avoid other residents from being exposed. The Administrator also informed LPA Wesley that due to the pandemic the facility has to abide by the stay at home orders which included: Stop facility visits, cease all medical appointments unless they are for a serious nature, and try to prevent the residents from leaving the facility going out into the community. The Administrator said that R1 continued arguing back and forth with staff because they wanted to go into the community. During the interview with R1, they informed the LPA they felt they were being threatened/verbally abused because the Administrator was trying to keep them inside, and staff would always tell them they needed to stay inside so they would not become ill with COVID-19. R1 also informed the LPA that they weren't actually being "threatened," they just felt threatened because they kept getting reminded about paying the rent and was told not to leave the facility which is "verbal abuse", and said they don't want any problems and feels that because they use a scooter to get around, there shouldn't be a problem if they wanted to go to the barbershop because they have money, a face mask, and their own scooter and feel that they are not a risk when they go into the community.

Regarding allegation: Resident is being financially abused while in care. During the interview with Administrator he denied allegations that R1 was being financially abused and advised that R1 handles their own finances and they even help R1 when they were having financial issues with their benefit checks and provided R1 with prepaid care and cigarettes. LPA Wesley interviewed R1 who advised that they had issues with their benefit

Continued on LIC 9099 C(Page 3).

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200715165238

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: 03/01/2021

NARRATIVE

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check and a accused the facility staff of not giving them a letter that was dated 05/07/20 in which they did not receive until 05/22/20 advising them that they were overpaid and they would start withholding $120 until it the debt is paid off. R1 said the facility tried to pull $900 from their account it caused and overdraft fee for $25, so they closed the account and opened a new account in the beginning of May 2020. R1 also stated that the overpayment was for something that occurred prior to them residing in the facility and that they could only afford to pay $600 a month to the facility because they also need to help their family with finances.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Office Manager Marili Barajas, and a hard copy was provided via email to obtain signature. There are no citations issued, exit interview conducted.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

LIC9099 (FAS) - (06/04)

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