198603137-5-10-2021-28-AS-MVAO-C2YNF3-20210513102452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 05/07/2021
Date Signed: 05/10/2021 02:19:38 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
10/05/2020 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20201005091021

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: 52	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	07:30 PM
MET WITH:	Adam Zenou, Licensee		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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Due to lack of adequate supervision, resident AWOLed from the facility
Staff member hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint tele-visit for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this complaint investigation was conducted telephonically with Adam Zenou, Licensee.

The investigation consisted of the following: On 5/7/21, LPA Almaraz conducted interviews with Licensee, Staff #1-5, Residents #1-4, and attempted to interview Resident #5. LPA requested copies of: Staff and Resident Roster, Resident #1-5 files and Incident Report.

The investigation revealed the following: On 10/2/2020, Resident #5 was upset and attempted to elope from the facility because the resident did not want to be at the facility. Resident #5 was a new resident and was having difficulty adjusting to residents new place. (Continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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-20201005091021

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: 05/07/2021

NARRATIVE

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Interviews conducted with staff and residents, revealed although the resident walked out the front gate, Caregiver #5 was with the resident at all times. Interviews revealed they did not force the resident to walk back inside the gate and were trying to let the resident relax. LPA learned caregivers were talking and counseling the resident inside the facility and outside. All interviews stated the resident never left the facility alone and was with Caregiver #5 being re-directed. Interviews also revealed the resident was kicking and scratching staff while attempting to leave. All interviews stated although the resident was hitting staff no one hit the resident at any point. All caregivers stated they did not see any marking's on Resident #5. LPA interviewed a staff member from the hospital who stated the resident did not have any markings' on residents body.

Based on LPA's interviews conducted, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Licensee and a hardcopy was provided via email for signature. Signatures on hardcopy.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

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