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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 04/29/2022
Date Signed: 04/29/2022 04:14:58 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,
, CA
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 Gail Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210416101629
FACILITY NAME:LE BLEU CHATEAUFACILITY NUMBER:
198603136
ADMINISTRATOR:SOKOLOWSKI, MICHAELFACILITY TYPE:
740
ADDRESS:1900 GRISMER AVETELEPHONE:
(818) 843-3141
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 96DATE:
04/29/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marili BarajasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff unlawfully evicted resident.
INVESTIGATION FINDINGS:
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 On 04/29/2022 (11:00 AM), Licensing Program Analyst (LPA) Gail Johnson arrived at Burbank Senior Villa East, formerly named Le Bleu Chateau and conducted an unannounced subsequent complaint visit. LPA met with Manager Marili Barajas. LPA Johnson explained the purpose of today’s visit.

Investigation consisted of the following:

LPA reviewed and obtained the following documents: 30 day notice and fax receipt to CCL, rent payment invoices, R1 Resident Departure Form, Admission Agreement, County of Los Angeles Sheriff’s Department Receipt for Possession of Real Property (May 3, 2021), R1 Face Sheet, and R1 Physician’s report. LPA conducted interviews with House Manager Marili Barajas and R1.


Conitnued on LIC-9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
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-20210416101629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: LE BLEU CHATEAU
FACILITY NUMBER: 198603136
VISIT DATE: 04/29/2022
NARRATIVE
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Investigation revealed the following: based on the review of records, interviews with relevant staff and all documents regarding R1: Licensee provided a 30 day notice / fax cover sheet sent to CCLD, rent payment invoices, Resident Departure Form, Admission Agreement, Sheriff’s Department Receipt for Possession of Real Property, Face Sheet, and Physcian’s report. Regarding the allegation “Staff unlawfully evicted a resident.” Although the allegation 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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210416101629
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: LE BLEU CHATEAU
FACILITY NUMBER: 198603136
VISIT DATE: 04/29/2022
NARRATIVE
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Investigation revealed the following:

Allegation- Staff Unlawfully Evicted Resident

Based on the review of records and interviews conducted, LPA found that R1 was provided a 30 day notice on 10/20/2020. LPA Johnson conducted and interviewed with House Manager Barajas, who stated that the 30 Day Notice was issued to R1 for failure to pay rent, as R1 stopped paying rent in October of 2020. House Manager Barajas stated that assistance to secure a placement at a new facility was offered; however, R1 declined assistance and remained residing at the facility until April 19, 2021. R1 moved from the facility independently on April 19, 2021. LPA Johnson conducted an interview with R1, who stated that he understands the purpose for the eviction was because rent was not being paid and he made a decision to move from the facility and now lives independently. Upon R1’s departure from the facility in April 2021, the Los Angeles Sherriff’s Department posted an order of Receipt of Real Property on R1’s room door. Based on evidence gathered, LPA did not find sufficient evidence to support the above mentioned allegation.

Although the allegation 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.

An Exit interview was conducted with House Manager Marili Barajas.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail JohnsonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3