198603136-5-10-2021-28-AS-LHIS-C6TVCW-20210913161949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603136
Report Date: 05/07/2021
Date Signed: 05/10/2021 12:12:29 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
04/02/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210402150740

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: 66	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	04:13 PM
MET WITH:	William Boles, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident fell while in care resulting in fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver the finding for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with William Boles, the facility Administrator.

On 4/7/2021, LPA Chan conducted telephone interviews with the Administrator, Office Manager, 7 residents, and 3 staff. LPA received the staff and resident rosters, along with documents pertaining to Resident #1 (R1). LPA made several attempts to interview R1.

Regarding allegation, Resident fell while in care resulting in fracture. It is alleged that resident fell from wheelchair and sustained a hip fracture. It was also noted that the resident will usually ask for help but did not on this occasion.
(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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 28-AS-20210402150740

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: 05/07/2021

NARRATIVE

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LPA interviewed 3 Staff who work closely with Resident #1 and all stated that the resident had an unwitnessed fall. The morning staff found R1 on the floor around 8am, while doing round checks and passing out medication at the same time. Staff immediately called for assistance from other caregivers. R1 complained of pain on the left arm and left leg, therefore, Staff called for the ambulance to escort R1 to the hospital. Staff stated that R1 requires assistance but does not have a one-to-one caregiver. Staff also indicated that R1 does not ask for assistance often and since the room door is normally left ajar, they would check on resident more frequently. According to staff, R1 did not have any previous falls. LPA reviewed the Physician’s Report for R1 which indicated that resident is wheelchair bound but is able to communicate needs and does not require continuous bed care. LPA also interviewed 7 residents who all indicated that the staff would check on them often and if they request for assistance, staff would come quickly. Based on interviews conducted, there was no indication of neglect or lack of supervision coming from facility staff.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

A telephonic exit interview was conducted with the Administrator. A hard copy of this report was emailed for a signature and the appeal rights were also provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

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