<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:50:32 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
05/25/2021 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210525114334
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: 64DATE:
06/02/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:William Boles; AdministratorTIME COMPLETED:
03:03 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility refused to provide resident's medical records.
Residents not accorded privacy during diaper changes.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) David Sicairos and Luis Mora conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Administrator William Boles and explained the reason for the visit.

Investigation consisted of the following: during today's visit, LPA toured the facility and obtained copies of staff and resident rosters. LPA also interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #2 (R2) - Resident #12 (R12).

Investigation revealed the following: in regards to the allegation "facility refused to provide resident's medical records", it is alleged that Former Resident #1 (FR1) has requested her medical records from the facility, but facility refuses to provide them to her.

(CONTINUED ON 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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-20210525114334
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: 06/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews conducted with Administrator and Office Manager revealed that facility has not refused to provide medical records to FR1. Facility is currently in contact with FR1 and FR1 has been advised she can pick them up or they can be emailed to her. Facility will be obtaining correct email address for FR1 and will email documents to FR1. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "residents not accorded privacy during diaper changes", it is alleged that staff members leave residents bedroom doors open during diaper changes. Interviews conducted with staff members all indicated that residents bedroom doors are always shut during a diaper change in order to provide them with privacy. During tour of facility, LPAs did not observe any staff member providing a diaper change with residents door open. 8 out 10 residents interviewed indicated that they have not observed facility staff conducting diaper changes with resident doors open. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
05/25/2021 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210525114334

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: 64DATE:
06/02/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:William Boles; AdministratorTIME COMPLETED:
03:03 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yell at the residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) David Sicairos and Luis Mora conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Administrator William Boles and explained the reason for the visit.

Investigation consisted of the following: during today's visit, LPA toured the facility and obtained copies of staff and resident rosters. LPA also interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #2 - Resident #12 (R12).

Investigation revealed the following: In regards to the allegation "staff yell at the residents", it is alleged that facility staff members, made inappropriate comments towards FR1, and made fun of her while she was a resident at the facility. Staff members also allegedly yell at other residents at the facility. Interview conducted with Administrator revealed that he has spoken to Staff #1 (S1) about concerns that have been brought up to him regarding the way she communicates with residents.

(CONTINUED ON 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210525114334
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: 06/02/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Additionally one of the staff members interviewed indicated that they have witnessed S1 yell at residents. 3 out of the 10 residents interviewed indicated that they have witnessed S1 yell at residents. Interview with S1 revealed that she does raise her voice, however does it with residents who are hard of hearing. Therefore there was sufficient evidence to corroborate with this allegation.

Based on LPAs observations and interviews which were conducted record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210525114334
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: 06/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2021
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator to ensure all residents be accorded dignity in their personal relationships with staff and residents. Administrator to conduct all staff training on Resident Personal Rights and submit sign in sheet of staff members who attend training by 06/23/21.
8
9
10
11
12
13
14
During interviews with staff and residents, it was revealed that Staff #1 (S1) yells at residents. This poses an immediate Health, Safety, and/or Personal Rights risk to the residents in care.
8
9
10
11
12
13
14
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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5