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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 01/04/2021
Date Signed: 01/04/2021 04:40:24 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
05/16/2019 and conducted by Evaluator Renee Arterberry
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190516152205
FACILITY NAME:LE BLEU CHATEAU - GOLDFACILITY NUMBER:
198603137
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(310) 308-4215
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 72DATE:
01/04/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Marili Barjajas, Office ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Lack of supervision resulting in a resident wandering out of the facility
Facility does not have enough staff to care for residents
Facility staff are requiring residents to wear diapers in order for staff not to assist with toileting needs
Residents responsible party was not notified of resident wearing a wrist band
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ren’ee Arterberry initiated a Complaint Follow-Up Visit to investigate the allegations noted 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 Office Manager, Marili Barjajas of Le Blue Chateau-Gold and the allegations were discussed.

The investigation consisted of the following: On 07/07/2020 the LPA interviewed the office manager and she shall be referred to as S1 and three caregivers and they shall be referred to as, S2 S3 and S4. The LPA also interviewed the weekday Activity Director and she shall be referred to as, AD. A weekend Receptionist and she shall be referred to as S5. A weekend caregiver and she shall be referred to as S6. The following documents were requested and provided by the office manager: List of Resident Roster, Identification and Emergency information, Facility Activity Schedule, Physician's Reports for R5 and R7 and Facility Work Schedule (including weekend shifts). Using the Resident Roster the LPA randomly selected and interviewed a total of seven residents and they shall be referred to as: R1 through R7.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
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 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
VISIT DATE: 01/04/2021
NARRATIVE
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The investigation reveal the following: A resident who shall be referred to as, R8 is deceased. However, the file for R8 was reviewed. The LPA attempted to interview a resident who shall be referred to as, R9 but he failed to respond.

Lack of supervision resulting in a resident wandering out of the facility: the office manager and all staff, who knew R8 state that he wondered throughout the inside of the facility. The staff deny observing or being told that R8 wondered outside of the facility. All residents deny that they are wonderers. A review of the residents files, does not reveal that any are wonderers. There is no indication that R8 was a wonderer. Or that he ever was seen outside the facility, in the parking area or car port. A review of the facility file for R8 does not reveal Special Incident Reports (SIR) noting that R8 was observed to be outside the facility.
Facility does not have enough staff to care for residents: It was observed on the weekend that there were no caregivers working on weekends. S1 state that there are three caregivers working on each weekends shift. The caregivers state that it had not been reported to them, by residents that there are not enough weekend caregivers. The residents state that they have seen caregivers working every weekend and their needs are being met. Facility staff are requiring residents to wear diapers in order for staff not to assist with toileting needs: S1 denied the allegation by stating they do not require continent residents to wear diapers. All caregivers deny that they were instructed by management to place continent residents in diapers. S2 is the facility Supervisor for all Caregivers. S2 has worked for Le Bleu Chateau - Gold for eighteen years (18). Among other duties, S2 is responsible for hiring, firing and training the caregivers. S2 state that she would not and have not trained or instructed any caregiver to put diapers on residents who are not incontinent. R1, R5, R6 and R7 are diagnosed as incontinent as noted on the Physician Reports. R2, R3, and R4 state that they do not wear diapers and caregivers have not instructed them to wear diapers. Therefore, caregivers have not put diapers on residents who are not diagnosed as incontinent. R2, R3, and R4 do not wear diapers because they do not need them. R5 and R7 state that they are incontinent and require assistance in changing their diapers. The caregivers check them during the night, day and on the weekends. The caregivers change their diapers when its needed and they are not left in wet diapers.
Residents responsible party was not notified of resident wearing a wrist band: S1 state that each resident is told during admission about the identification bracelet. If the resident is admitted with a family member, under conservatorship, guardianship or have an authorized representative they are told at the time the resident is admitted. If the resident have an authorized representative, under guardianship or conservatorship S1 state that she will call to inform them of the identification bracelet. Some of the residents interviewed do not have a conservator, guardian or authorized representative .
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
VISIT DATE: 01/04/2021
NARRATIVE
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The investigation reveal the following: A resident who shall be referred to as, R8 is deceased. However, the file for R8 was reviewed. The LPA attempted to interview a resident who shall be referred to as, R9 but he failed to respond.

Lack of supervision resulting in a resident wandering out of the facility: the office manager and all staff, who knew R8 state that he wondered throughout the inside of the facility. The staff deny observing or being told that R8 wondered outside of the facility. All residents deny that they are wonderers. A review of the residents files, does not reveal that any are wonderers. There is no indication that R8 was a wonderer. Or that he ever was seen outside the facility, in the parking area or car port. A review of the facility file for R8 does not reveal Special Incident Reports (SIR) noting that R8 was observed to be outside the facility.
Facility does not have enough staff to care for residents: It was observed on the weekend that there were no caregivers working on weekends. S1 state that there are three caregivers working on each weekends shift. The caregivers state that it had not been reported to them, by residents that there are not enough weekend caregivers. The residents state that they have seen caregivers working every weekend and their needs are being met. Facility staff are requiring residents to wear diapers in order for staff not to assist with toileting needs: S1 denied the allegation by stating they do not require continent residents to wear diapers. All caregivers deny that they were instructed by management to place continent residents in diapers. S2 is the facility Supervisor for all Caregivers. S2 has worked for Le Bleu Chateau - Gold for eighteen years (18). Among other duties, S2 is responsible for hiring, firing and training the caregivers. S2 state that she would not and have not trained or instructed any caregiver to put diapers on residents who are not incontinent. R1, R5, R6 and R7 are diagnosed as incontinent as noted on the Physician Reports. R2, R3, and R4 state that they do not wear diapers and caregivers have not instructed them to wear diapers. Therefore, caregivers have not put diapers on residents who are not diagnosed as incontinent. R2, R3, and R4 do not wear diapers because they do not need them. R5 and R7 state that they are incontinent and require assistance in changing their diapers. The caregivers check them during the night, day and on the weekends. The caregivers change their diapers when its needed and they are not left in wet diapers.
Residents responsible party was not notified of resident wearing a wrist band: S1 state that each resident is told during admission about the identification bracelet. If the resident is admitted with a family member, under conservatorship, guardianship or have an authorized representative they are told at the time the resident is admitted. If the resident have an authorized representative, under guardianship or conservatorship S1 state that she will call to inform them of the identification bracelet. Some of the residents interviewed do not have a conservator, guardian or authorized representative .
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
05/16/2019 and conducted by Evaluator Renee Arterberry
COMPLAINT CONTROL NUMBER: 28-AS-20190516152205

FACILITY NAME:LE BLEU CHATEAU - GOLDFACILITY NUMBER:
198603137
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(310) 308-4215
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 72DATE:
01/04/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Marili Barjajas, Office ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility failed to provide residents with activities:
Facility failed to provide hot water for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ren’ee Arterberry initiated a Complaint Follow-Up Visit to investigate the allegations noted 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 Office Manager, Marili Barjajas of Le Blue Chateau-Gold.

The investigation consisted of the following: on 05/22/2019 LPA Rivas and the Office Manager Rosie Lucrecio tested the hot water temperature in the following resident bedrooms: #300, #301, #309, #314, #316, #411, #421, 423 and #427. During the course of todays visit, 07/07/2020 the LPA interviewed the office manager and she shall be refered to as S1. S2 was interviewed and she is the Supervisor of the Caregivers, S3 was interiewed and she is a caregiver and S4 who is a weekend caregiver. In addition, the LPA also interviewed the weekday Activity DIrector and she shall be refered to as, AD. A weekend receptionist and she shall be referred to as, S5 and another weekend caregiver who is refererd to as S6. Another weekend caregiver was interviewed and she shall be refered to as, S7.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
VISIT DATE: 01/04/2021
NARRATIVE
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In addition, a staff member who is one of the facility cook's was interviewed and he shall be referred to as S8. The following documents were requested and provided by the office manager: List of Resident Roster and Facility Activity Schedule. The investigation reveal the following: Facility failed to provide hot water for residents: It is alleged that the facility did not have hot water on 5/13/19 to 5/15/2019. Although S1 did not recall specific dates noted on this complaint as not having hot water. S1 state that due to past boiler problems it is highly likely that they did not have hot water for a few days. The staff who were employed and working at the facility in the month of May 2019 state that due to facility repairs there were occasions when the facility did not have hot water. The residents could not recollect if hot water was available in May of 2019.

Facility failed to provide residents with activities: it is alleged that activities are not being provided during the weekends. S1 state that they do not have a staff member who is designated as a weekend activity director. However, the weekend receptionist S5 perform double duties acting as the activity director and receptionist. S5 state that prior to COVID she provide movies/CDs for the residents to watch. S5 conduct arts and crafts and dance with the residents. AD is one of the facility activity directors state that she provide activities for the residents during the week and do not work the weekends. AD also state that S8 who is the facility weekend cook, perform double duties by playing music (on his cellphone) for the residents. The residents all state, that there is no activity director on the weekends. When asked what do they do on the weekends they state that they watch TV. When asked if any other activities are conducted they stated no. The LPA also asked the residents prior to COVID-19 what activities were conducted during the weekends and they re-stated, "they watch TV and movies". A review of the facility Activity Calendar reveal that on the weekends the following activities are conducted: bible study and movies. The State of California, Department of Social Services Community Care Licensing investigated the allegations of; facility failed to provide residents with activities and facility failed to provide hot water for residents. The finding based on a preponderance of the evidence standards, interviews conducted and documents provided is substantiated. The staff who worked at this facility in May 2019 state that due to repairs to the roof or boiler repairs there were times when there was no hot water at the facility. All residents state that they watch TV on the weekend and no other activities are provided.
Two deficiencies cited under California code of Regulations Title 22
An exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email for signature. Appeal Rights Given

Signatures on hardcopies.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: based on the interviews
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The administrator or office manger shall provide to CCL to the attention of LPA Arterberry a written statement that he/she will ensure, to the best of their ability, that hot water at available at the facility at all times. The written statement shall be provided to CCL by the POC Date.
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of the staff who worked at the facility in May 2019 there were occasions when hot water was not available at the facility.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2021
Section Cited
CCR
87208(a)
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Plan of Operation: Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which
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The administrator or office manager shall develope a written plan to provide the weekend activities noted on the Activity Calandar. The written plan shall be sent to CCL by the POC Date.
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would affect the services to residents shall be submitted to the licensing agency for approval. The requirement was not met as evidence by, all residents state that the only activities provided to them on the weekends is watching TV.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20190516152205
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 - GOLD
FACILITY NUMBER: 198603137
VISIT DATE: 01/04/2021
NARRATIVE
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However, some have authorized representatives but were not present during time of admission. R3 state that her daughter admitted her and was told of the identification bracelet. The other residents did not remember if they were told about the identification bracelet.

A review of the Physician's Reports for R5 and R7 and Facility Work Schedule (including weekend shifts). A review of the Physican's Reports reveal that R5 and R7 are incontinent. A review of the Work Schedule reveal a sufficient amount of caregivers assigned to work the weekend shifts.

The State of California, Department of Social Services Community Care Licensing investigated the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations: Lack of supervision resulting in a resident wandering out of the facility, facility does not have enough staff to care for residents and facility staff are requiring residents to wear diapers in order for staff not to assist with toileting needs, did or did not occur. Therefore, the complaint investigation of the allegations is unsubstantiated. The residents state that they have seen caregivers working every weekend and their needs are being met. The caregivers have not put diapers on the continent residents and have not asked them to put diaper on. The continent residents deny being told by caregivers to put diapers on and have not worn diapers. R8 wondered around the inside of the facility and was not observed to be outside; driveway by carport. Although, most of the residents did not remember if they, or their authorized representative was informed of the identification band/bracelet. R3 state that her daughter admitted her and was told of the identification bracelet. Based on a preponderance of the evidence standard, interviews conducted and documents reviewed the finding is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted via telephone with the administrator and a hardcopy was provided via email for signature. Signatures on hardcopies.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee ArterberryTELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8