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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603137
Report Date: 08/02/2021
Date Signed: 08/02/2021 12:08:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 - GOLDFACILITY NUMBER:
198603137
ADMINISTRATOR:ZENOU, ADAMFACILITY TYPE:
740
ADDRESS:1911 GRISMER AVETELEPHONE:
(818) 295-2727
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:100CENSUS: 61DATE:
08/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Adam Zenou, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit on 8/2/21 regarding a special incident report that was submitted on 7/30/21.

LPA Chan toured the facility inside and out with the Licensee, Adam Zenou and Co-Manager, Mochi Bercovich. Most residents were observed to be in their rooms. A group of residents was participating in an activity with the Activity Director on the second floor. LPA did not observed any health and safety concerns during the visit.

An exit interview was conducted and a copy of this report was given to the licensee.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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