198603137-9-21-2021-28-AS-CYEE-C7FSPC-20211003140252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 09/20/2021
Date Signed: 09/21/2021 07:04:12 AM

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
01/22/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210122150159

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: 59	DATE:	09/20/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	S-1		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff disclosed resident's confidential information.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial investigation on 01/28/21 for the allegation listed above. During today's visit, LPA met with S-1 and discussed the purpose of today's visit. During this investigation, LPA obtained the following: Staff Roster, Resident Roster, List of Resident that have moved out from this facility from November 2020 through January 2021, blank form for Resident Discharge (“Resident Departure”) and a blank form for Release of Client/Resident Medical Information.

Allegation: Facility staff disclosed resident's confidential information.
During this investigation, per staff interview, R-1 was not a resident at this location. LPA reviewed the list of Residents that have been discharged from this facility from November 2020 through January and 2021 and it revealed that R-1 did not reside at this facility. Per staff interview, all staff are trained on releasing confidential information/HIPAA. Per staff interview, there has not been any complaints of staff releasing any confidential information to others. Interview and documentation review do not corroborate this allegation. ***Refer to LIC9099C for the contination of this report.***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20210122150159

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: 09/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

Exit interview conducted, a copy of this report provided and appeal rights were provided to S-1

Note: LPA was experiencing technical difficulties during today's visit. .

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2