198603136-10-13-2022-28-AS-WSHO-CQZTVJ-20230418150357

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:26:55 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
04/16/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210416113753

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:	11:30 AM
MET WITH:	Staff #1: Marili Barrajas, Office Manager		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff inappropriately speak to residents in care.

Residents are not being provided their medications as prescribed.

Residents are being left in soiled diapers for long periods of time.

INVESTIGATION FINDINGS:

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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 allegations. An initial 10-Day virtual visit was conducted by LPA Glenn Trueman on 04/22/21 (via telephone) with S1 due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed two facility staff members (S1 & S5) and five residents in care (R2-R6). LPA/RA did not interview the following staff for the reasons noted: Staff #2 (Caregiver - resigned: 06/04/21), Staff #3 (Med Tech/Caregiver - resigned: 12/20/21)), Staff #4 (Med Tech - resigned: 05/11/21). Resident #1 was not interviewed; as the resident moved out of the facility on 04/01/21; however, attempts were made to reach the

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)

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Control Number 28-AS-20210416113753

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

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resident (via telephone), but to no avail. LPA/RA Ceniceros reviewed pertinent documents: Admissions Agreement (dated 03/05/20), Emergency I.D. & Information (03/05/20), Physician’s Report (dated 02/21/20), Pre-placement Appraisal Information (dated 03/05/20) for Resident #1; including facility staff roster and residents' roster; SIR (dated 02/19/21), Eight-Hour Medication Training (dated 02/16/22), Personal Rights training (dated 06/22/21), and Staff In-Service Training (dated 12/21/21).

Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that residents in care have not been spoken to inappropriately by facility staff. Staff Members have not received complaints from residents in care and/or their responsible person(s) regarding same. A review of an SIR (dated 02/19/2) documented an incident (Aggressive Act/Self & Aggressive Act/Staff) that occurred involving Resident #1 towards Staff #4 (Med Tech); whereby, Resident #1 had become aggressive towards Staff #4. Resident #1 had been drinking alcohol at the facility which was found in Resident #1's room. Resident #1 became increasingly aggressive and began yelling obscenities (i.e., racial slurs at staff, EMTs, and police officers). Resident #1 was transported to the hospital for further evaluation. LPA/RA Ceniceros also reviewed facility's Personal Rights training which was conducted on 06/22/21.

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 PERSONAL RIGHTS: Staff inappropriately speak to residents in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that residents in care are being administered their medications by the med techs. LPA/RA Ceniceros toured the facility's medication room and observed the computerized "QUICK-MAR" system utilized for the residents' medication administration records and residents' medications stored in a secured cart. LPA/RA Ceniceros also reviewed the facility's last 8-Hour Medication Training that was conducted on 02/16/22 by a pharmacy's nurse consultant.

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 MEDICATIONS: Residents are not being provided their medications as prescribed is found to be UNSUBSTANTIATED.

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)

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Control Number 28-AS-20210416113753

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

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Regarding Allegation #3: this investigation revealed based on interviews conducted corroborated that facility staff have not left incontinent residents in soiled diapers for long periods of time. Facility staff members had not received a complaint from residents in care and/or their responsible person(s) regarding same. A review of Resident #1's "Physician's Report" (dated 02/21/20) documented under "Physical Health Status" that the resident does not have bowel impairment or bladder impairment. A review of Resident #1's "Pre- placement Appraisal Information" (dated 03/05/20) documented that the resident is incontinent at times and wears pull-ups for precaution. A review of the facility's "Staff In-Service" training on the topic of "Checking all residents every two (2) hours as needed" was conducted on 12/21/21.

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: Residents are being left in soiled diapers for long periods of time is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the Complaint Report provided to Staff #1: Marili Barajas, 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)

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