198603137-11-18-2020-28-AS-MVAO-C2QRH9-20210505130159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 11/18/2020
Date Signed: 11/18/2020 03:47:47 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
11/13/2020 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201113094401

FACILITY NAME:	LE BLEU CHATEAU - GOLD		FACILITY NUMBER:	198603137
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1911 GRISMER AVE		TELEPHONE:	(818) 295-2727
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 73	DATE:	11/18/2020
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Michael Sokolowski, Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a complaint investigation 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 explained telephonically to receptionist Irma Perez. Assistant Administrator Michael Sokolowski was available later.

The investigation consisted of the following: Staff (S1- S3) were interviewed. Hospital case manager, and family member (F1) were interviewed. Resident (R1's) documents were requested and reviewed. The following items were obtained: Identification and Emergency Information/Face Sheet, Admission Agreement, Physician Report, Pre-Placement Appraisal Information, Resident Departure Form (11/11/20), Inventory of Personal Effects, three (3) incident reports, LIC 500 Personnel Report, and resident roster.

See LIC 9099C for continuation of report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

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-20201113094401

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: 11/18/2020

NARRATIVE

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Allegation: "Illegal Eviction"- Based on interviews conducted and document review the findings revealed that resident (R1) was transferred to Southern California Hospital on Nov. 2, 2020, and then discharged to a skilled nursing facility (SNF). According to staff (S3) facility requested that hospital complete a “deeper evaluation” of resident (R1) before discharged back to the facility due to continual issues/needs observed prior to hospital transfer. Hospital staff confirmed that R1 was transferred to a SNF. According to facility staff, R1’s family members were notified of hospitalization, but they were never contacted about an eviction. All staff denied issuing an eviction notice to R1. Family member (F1) was interviewed and acknowledged that an eviction notice was not issued. However, F1 stated that based on the information provided to hospital personnel and conversation with staff (S3) the information obtained was interpreted as a verbal eviction. On November 11, 2020, family member (F1) went to the facility to pick-up R1’s personal belongings, and signed the discharge form. Therefore, the findings indicate resident (R1) was discharged from the facility, and not evicted.

Based upon document review and interviews conducted the findings indicate that, although the allegation may have happened or is 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 Administrator Michael Sokolowski. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

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