198603136-7-16-2021-31-AS-MVAO-C5HQB5-20210802120056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 07/16/2021
Date Signed: 07/16/2021 03:56:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200508134915

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: 69	DATE:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bill Boles		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is financially abusing resident

INVESTIGATION FINDINGS:

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An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA)Wendell Smith . Upon arrival LPA met with administrator Bill Boles and explained the reason for this visit.

Regarding the allegation listed above it is being alleged that the Licensee/Administrator stole resident 1 (R1's) identity, opened a bank account under his name and that his social security Income SSI is being deposited into this new account. Additionally, it is being alleged that administrator stole a money order from R1 in the amount of $500.00.
Initial 10-day complaint visit was conducted on 5/13/2020 by LPA Yelena Avetisyan. During the visit LPA Avetisyan conducted interview with the administrator and requested document to be submitted related to the allegation listed above. Additionally, on 5/15/2020 LPA Avetisyan conducted interview with Resident 1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jill Nakata	TELEPHONE: (818) 596-4377
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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 31-AS-20200508134915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LE BLEU CHATEAU	FACILITY NUMBER: 198603136
	VISIT DATE: 07/16/2021

NARRATIVE

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Interviews conducted and records revealed the following. upon admission to the facility resident 1 (R1) signed an "Authorization and Agreement for the licensee to Handle Resident Funds” The form indicates that the resident is authorizing Automatic transfer of Deposits to pay for care costs. The form was submitted to social security administration and R1's payments were automatically deposited into the account. When interviewed administrator stated that R1 was officially discharged from the facility 4/30/2020 at which time the agreement was terminated, and the account closed. Administrator also denied taking and cashing a $500.00 money order from R1's room. Additionally, administrator informed LPA that the resident spoke with him about the money order as well, however resident did not have receipt, money order #, the date it was purchased or any information that could be used to try and determine what happened to the money order.

Based on the information obtained, the allegations of Facility is financially abusing resident is unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Jill Nakata	TELEPHONE: (818) 596-4377
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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