198603137-6-16-2021-28-AS-CYEE-C79LVU-20210927090605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 06/14/2021
Date Signed: 06/16/2021 02:41:00 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
04/16/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210416093023

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: 51	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Irma Perez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Unexplained fracture

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a visit to deliver the findings for the allegation listed above. LPA Spencer was met with Irma Perez, receptionist, and explained the purpose of today’s visit.

The initial health and safety check was conducted by LPA Kruz Long on 4/16/21 who obtained a copy of the staff and resident roster and toured the physical plant. During the course of the investigation, resident #1’s (R1) medical records and a copy of the Burbank Police Department report was obtained. The complainant, executive director, staff #1, staff #2, and R1’s attending physician were interviewed.

The investigation revealed the following: R1’s medical records were reviewed and showed that R1 was admitted to the hospital on 3/30/21 due to signs of a stroke. The tests completed showed that R1 did have a stroke and the MRI revealed a small fracture on the base of the skill without underlying hematoma or mass. The notes stated that the fracture possibly occurred from a previous injury, timeframe unknown. The Burbank Police Department report stated that there were no signs of foul play so the case was closed. ***See LIC9099C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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-20210416093023

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: 06/14/2021

NARRATIVE

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R1’s attending physician was interviewed and confirmed that R1 had a small fracture, but that it was an older fracture and was not a major injury. The attending physician stated that the possible causes were a fall or hitting the head on an object, but stated that it was not the cause of the stroke. The executive director, S1, and S2 stated that R1 has no history of falls and that she was immediately taken to the hospital on 3/30/21 when found slumped in wheelchair with signs of possible stroke. Staff denied any allegations of abuse or neglect. The police report stated that they received a report of possible assault, but per doctors, the fracture was from an old surgery and there were no signs of foul play so the case was closed.

Based on interviews and record reviews, the investigation revealed that 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 is Unsubstantiated.

An exit interview was conducted with staff Irma Perez and a hard copy of the report was provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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