198603136-6-7-2021-31-AS-MVAO-C5APTG-20210726113554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:24:36 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
06/16/2020 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200616103615

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: 65	DATE:	06/07/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	William "Bill" Boles and Marili Barajas		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident not administered medication as prescribed.
Staff dispose resident’s medication.
Staff not keeping an accurate medication log.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with William "Bill" Boles (Facility Administrator) and Marili Barajas (Office Manager) and discussed the pupose of today's visit.

On 06/23/20, LPA initiated this investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted this investigation telephonically with Marili Barajas (Office Manager) as Michael Sokolowski (Facility Administrator) was not available. Note: As of today's visit, Mr. Sokolowski is no longer working at this facility. LPA obtained relevant documentation for this complaint investigation.

During today's visit, LPA interviewed Staff #1 through Staff #5 (S-1 through S-5) and Resident #1 through Resident #4 (R-1 through R-4). LPA was unable to interview Resident #5 (R-5) as R-5 was sleeping at the time of this visit. LPA was unable to interview Resident #6 (R-6) as R-6 is no longer residing at this facility and is unreachable. ***Refer to LIC 9099C for the continuation of this report***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

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 3

Control Number 31-AS-20200616103615

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: 06/07/2021

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

Allegation: Resident not administered medication as prescribed.
During this investigation, LPA interviewed the Office Manager, Staff #1 through Staff #4 (S-1 through S-5) and Resident #1 through Resident #4 (R-1 through R-4). LPA was unable to interview Resident #5 (R-5) as R-5 was sleeping at the time of this visit. LPA was unable to interview Resident #6 (R-6) as R-6 is no longer residing at this facility and is unreachable. Staff interviews revealed that medication is administered to Residents as prescribed. Interviewed Staff indicated they have not received any concerns/complaints from anyone pertaining to medication not being administered as prescribed. Interviewed Staff indicated administrated medications are documented on the Medication Administration Record (MAR). Interviewed Staff indicated they are trained in Medication Administration, Resident Rights and Mandated Reporting. (4) out of (6) interviewed Residents indicated Staff administer medication as prescribed. (4) out of (6) interviewed Residents indicated they do not have any concerns on medication administration. Staff and Resident interviews do not corroborate this allegation.

Allegation: Staff dispose resident’s medication.
During this investigation, LPA interviewed the Office Manager, Staff #1 through Staff #4 (S-1 through S-5) and Resident #1 through Resident #4 (R-1 through R-4). LPA was unable to interview Resident #5 (R-5) as R-5 was sleeping at the time of this visit. LPA was unable to interview Resident #6 (R-6) as R-6 is no longer residing at this facility and is unreachable. Staff interviews revealed the following procedures for disposal of medications: disposals are completed by (2) staff at all times, the (2) staff take inventory of each medication and document/log/record the medication being disposed and medication is placed in a locked/secured bin that is provided by the pharmacy. Interviewed Staff indicated they have not received any concerns/complaints from anyone pertaining to medication not being disposed appropriately. Interviewed Staff indicated they are trained in Medication Disposal, Resident Rights and Mandated Reporting. Documentation reviewed for R-6 revealed that R-6 was taken to the hospital on 05/20/20 and was not discharged back to this facility. Per documentation reviewed, R-6's medications was disposed on 06/13/20 as they were not retrieved from this facility. R-6's belongings were taken on 06/02/20 and medications were left behind and were not retrieved. (4) out of (6) interviewed Residents were unaware of the resident's medication disposal process as they have not had any medications disposed. Staff and Resident interviews do not corroborate this allegation.

***Refer to LIC 9099C for the continuation of this report***

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20200616103615

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: 06/07/2021

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

Allegation: Staff not keeping an accurate medication log.
During this investigation, LPA interviewed the Office Manager, Staff #1 through Staff #4 (S-1 through S-5) and Resident #1 through Resident #4 (R-1 through R-4). LPA was unable to interview Resident #5 (R-5) as R-5 was sleeping at the time of this visit. LPA was unable to interview Resident #6 (R-6) as R-6 is no longer residing at this facility and is unreachable. Interviewed Staff indicated that all medication that is administrated is logged onto the Residents' log once it has been administered. Interviewed Staff indicated medication logs are accurate and up-to-date. Interviewed Staff indicated they have not received any concerns/complaints from anyone pertaining to Staff not keeping an accurate medication log. Interviewed Staff indicated they are trained in Medication Administration, Resident Rights and Mandated Reporting. (4) out of the (6) interviewed Residents indicated they have observed staff keeping accurate medication log/lists of their medication. (4) out of the (6) interviewed Residents indicated they do not have any concerns with their medication log. Staff and Resident interviews do not corroborate this allegation.

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 allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report and Appeal Rights were provided to Mr. Boles.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3