198603137-9-7-2022-28-AS-RORN-CJNMNN-20220927094549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 09/07/2022
Date Signed: 09/07/2022 12:10:22 PM

Unsubstantiated

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
12/30/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201230133738

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: 95	DATE:	09/07/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Silvia Valdez, Community Ambassador/Marketing Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.

Resident not properly hydrated while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #4 (S4): Emily Caluag, Receptionist; as Administrator (A1: Adam Zenou) was unavailable; therefore, LPA/RA met with Staff #5 (S5): Silvia Valdez, Community Ambassador/Marketing Director. LPA/RA spoke to S4 prior to entering the facility to conduct a risk assessment. S4 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of today's visit is to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 01/11/21 (via telephone) with Staff #1 (S1): Office Manager, Marili Barajas due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 9:30 a.m. - 10:30 a.m.) three (3) additional staff members. Resident #1 was not interviewed as the resident passed away. LPA/RA requested (between 10:30 a.m. - 11:00 a.m.) additional documents: Admission Agreement, Emergency ID & Information, and Death Report pertaining to Resident #1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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-20201230133738

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: 09/07/2022

NARRATIVE

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Regarding Allegation #1: this investigation revealed that Resident #1 had been transferred on 08/21/20 from (then) Le Bleu Chateau (#198603136) due to a decline in the resident's health condition. Resident #1 was hospitalized on 12/09/20 as a result of testing positive for COVID-19. Resident #1 was later transferred to a skilled-nursing facility (SNF) for twenty (20) days before returning to Le Bleu Chateau Gold (#198603137) on 12/24/20. Upon Resident #1's return from the skilled-nursing facility, Staff #2 (S2: Ma Nieva, Med Tech - A.M.) noticed redness to Resident #1's bottom (coccyx) and informed Resident #1's family member and requested home health. Kaiser Home Health Nurse followed up with Resident #1 after five (5) days. Staff #3 (S3: Ging Madrigal, Med Tech - P.M.) and Staff #7 (S7: Lien Seesee, Activities Director) met with the Kaiser Home Health Nurse who observed Resident #1's wound on 12/30/20 at 4:30 p.m. to only be slight redness to resident's bottom (coccyx). Interviews conducted corroborated that Kaiser Permanente Home Health Nurse did not leave notes and there were no other visits regarding Resident #1's wound care. Resident #1 passed away due to complications of COVID-19 based on the Death Report, dated 01/02/21.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident sustained a pressure injury while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1 was hospitalized for COVID-19 and no hospital records or discharge paperwork were made available to the facility for reporting Resident #1's diagnosis upon discharge from Kaiser Permanent Hospital on 12/09/20. Resident #1 was discharged to a skilled-nursing facility (SNF) for twenty (20) days before returning to Le Bleu Chateau Gold (#198603137) on 12/24/20. Upon Resident #1's return to the facility on 12/24/20, the resident was still positive for COVID-19. Resident #1 had been receiving home health care through Kaiser Permanente until R1's passing on 01/02/21.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident not properly hydrated while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #5 (S5: Silvia Valdez, Community Ambassador, Marketing Director)

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC9099 (FAS) - (06/04)

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