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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 06/21/2022
Date Signed: 06/21/2022 01:04:37 PM

Unfounded


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
10/16/2020 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201016114516
FACILITY NAME:LE BLEU CHATEAU - GOLDFACILITY NUMBER:
198603137
ADMINISTRATOR:ZENOU, ADAMFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 90DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Adam Zenou; Executive DirectorTIME COMPLETED:
01:19 PM
ALLEGATION(S):
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Facility staff financially abused resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Sicairos conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Executive Director Adam Zenou and explained the reason for the visit.

Investigation consisted of the following: during the initial televisit conducted on 10/22/20, LPA interviewed the former Administrator and obtained copies of Resident and Staff Rosters. During today's visit, LPA interviewed the Executive Director and obtained copies of Resident & Staff Rosters.

Investigation revealed the following: during today's interview with the Executive Director, it was confirmed that Resident #1 (R1) was never a resident of this facility. R1 was a former resident of the sister facility associated to this facility. This was verified by reviewing the "Customer Quick Report" which lists the sister facility address for R1. R1 is also not listed in the current facility roster.

(CONTINUED ON 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 2
Control Number 28-AS-20201016114516
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: 06/21/2022
NARRATIVE
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This agency has investigated the complaint alleging "Facility staff financially abused resident". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Exit interview held, and a copy of this report was provided.




SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2