198603136-8-25-2023-28-AS-LHIS-CVDN74-20230905101206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 08/25/2023
Date Signed: 08/25/2023 12:44:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210719151353

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:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Imelda Villanueva		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Administrator, Imelda Villanueva who assisted with today's visit.

Regarding the allegation that Resident #1 sustained pressure injuries while in care. The investigation was conducted by the department, and consisted of interviews with facility staff, interviews with medical personnel, and review of resident #1's medical records. The investigation revealed the following: Resident #1 was hospitalized on 7/18/21, and diagnosed with a stage III sacral ulcer and an unstageable right low back pressure ulcer. On 7/28/21, Resident #1 was discharged back to the facility, and was placed on hospice care on 7/30/21. On 8/27/21, Resident #1 was readmitted to the hospital, and was diagnosed with a stage III pressure ulcer of the left sacrum and debridement revealed a stage IV right low back pressure injury. It was determined that resident #1 received inadequate care at Le Blue Chateau resulting in worsening of her medical condition. The facility kept resident #1 with advanced dermal ulcers which was prohibited.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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-20210719151353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LE BLEU CHATEAU	FACILITY NUMBER: 198603136
	VISIT DATE: 08/25/2023

NARRATIVE

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Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An immediate civil penalty will be issued.

The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f).

Exit interview conducted. Civil penalties assessed. Copy of Report and appeal rights provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210719151353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: LE BLEU CHATEAU	FACILITY NUMBER: 198603136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/30/2023 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.	1 2 3 4 5 6 7	Licensee will ensure that Title 22 regulations are abided by as required. Licensee will ensure that the faciity does not retain residents with prohibited health conditions. Licensee will conduct an in service training with staff on section 87615, and will send proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Resident #1 was admitted to hospital on 7/18/21 with a stage 3 sacral ulcer, and an unstageable right low back pressure injury.	8 9 10 11 12 13 14
Request Denied Type B 08/30/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Licensee will ensure that Title 22 regulations are abided by as required. Licensee will ensure that residents personal rights are not violated. Licensee will conduct an in service training with staff on section 87468.2, and will send proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Resident #1's needs were not met as evidenced by staff interviewed stated that resident #1 was not changed as needed due to the facility not having sufficient staff at the time of the incident.	8 9 10 11 12 13 14

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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