198603137-10-20-2022-28-AS-FFIS-CKV2C5-20221104171610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:08:18 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
12/31/2020 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201231082101

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:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Adam Zenou		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not notify authorized representative of residents change in condition.

INVESTIGATION FINDINGS:

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On 10/20/22 Licensing Program Analyst (LPA) Ashley Calderon visited the above facility unannounced, to conduct a subsequent visit on a complaint investigation for the allegation listed above. LPA Calderon met with Business Manager Harlyn Onsik.

On 1/7/21, LPA Long conducted a initial complaint via telephonically. LPA Long interviewed Administrator Adam Zenou and requested a copy of the following documents: Staff/Resident roster, Resident #1's (R1) latest and prior: Physician Report, Needs and Services Plan, Pre-Apprasial, Admission Agreement,Medical Administration Records(MARS), Hospital/Doctor's appointment records, Power of Attorney/Responsible Party and Weight Chart.

Todays complaint investigation consisted of, LPA Calderon reviewing R1's Hospice Admission Documentation, Care Plan and Discharge Notes.In addition, R1's Facesheets,Admission Agreement, Controlled Substance Inventory, Progress Notes - Carelist, doctors reports, weight assessment chart, Emergency Information and MARS for 6/25/20-7/24/20 and 8/25/20 - 9/24/20.
(Continuation on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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-20201231082101

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: 10/20/2022

NARRATIVE

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LPA Calderon met with Community Ambassador Silvia Valdez and toured common areas of the physical plant. LPA observed the downstairs of the facility that consisted of the front patio, mainly lobby, additional lobby, TV room, court yard and dining room. LPA observed the upstairs of the facility which consisted of residents rooms and the activity room. LPA Calderon interviewed 7 staff, S#1-S7 (S1-S7) and 6 residents, R#1-R#6 (R1-R6).

Regarding allegation: Staff did not notify authorized representative of residents change in condition.
Based on documentation reviewed and interviews with staff the findings revealed that R1 was admitted to facility as a Dementia resident, resident was placed on a Hospice Program. Weight assessment chart shows progress of R1 weight loss in the months January 2020 - November 2020 showing no significant drop in weight. Based on R1 Hospice Care Plan R1 was discharged November 2020 due to prognosis extended and R1's condition was stabilized; both daughter and facility staff were notified. S7 reported that responsible party was notified about R1's self-being, condition and any changes if applicable on a weekly bases and hospice services were at the facility 3 times a week and daughter once a week. S4 and S7 and Hospice company were verbally communicating and providing updates on R1's health. S1-S4 and S6-S7 stated that they document weight and feeding intake on Carelist document and report changes to doctors, and follow doctors orders. Based on Admission Agreement R1 had a single room.

Based on LPAs observation and interviews although the allegations may or may have happened or is valid , there is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

An exit interview was held with Community Ambassador Silvia Valdez, reports were provided and appeal rights were given.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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