197800441-5-5-2022-11-AS-UCOL-CENMY9-20220522100111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800441
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:28:08 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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2022 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20220428132905

FACILITY NAME:	CHEZ BON GUEST HOME		FACILITY NUMBER:	197800441
ADMINISTRATOR:	ARI SAKOFF		FACILITY TYPE:	735
ADDRESS:	1206 WALNUT AVE		TELEPHONE:	(562) 591-1411
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	82	CENSUS: 82	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Ari Sokoff		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Staff did not safeguard a resident’s personal property
Staff do not ensure resident has nourishment
Staff do not ensure resident has fluids

INVESTIGATION FINDINGS:

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On 05/05/22 Licensing Program Analyst (LPA) Jade Jordan conducted an un-announced visit, regarding the allegation(s) above. LPA was met by Facility Administrator, Ari Sokoff. The purpose of the visit was explained.

Investigation consisted of: Physical Plant Tour, Interviews with Staff, and Clients, Record Review of Requested Copies of documents (Needs and Service Plan, Physician Report, Personnel Inventory, PNI, Payee designation)

Regarding Allegation " Staff did not safeguard a residents personal property"
Interviews with Administration stated that the Facility is C1’s Payee. C1 receives weekly cash. Staff 1 (s1) stated they have not received any complaints about missing ID’s , Or Debit Card. Facility does not hold ID’s /Debit cards unless Client requests to be safeguarded. According to S1 C1 did not ask for ID to be safeguarded and were not aware that C1 had a Bank Debit card.

******************* Continued on 9099 C********************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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 11-AS-20220428132905

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHEZ BON GUEST HOME	FACILITY NUMBER: 197800441
	VISIT DATE: 05/05/2022

NARRATIVE

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Record Review of C1’s personal inventory, did not list an ID, or Debit Card. Record Review revealed that C1 needs help with Money Management. Interviews conducted with Clients in Care C2-C9 revealed that they have not had an issue lost or stolen ID/Debit cards.

Based on interviews, record review, and observation the Department finds that;

“Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding Allegation(s): Staff do not ensure resident has nourishment; Staff do not ensure resident has fluid

Interviews conducted with S1 revealed that C1 has not had a change in eating or drinking. Meals are served 3x’s a day, Snacks are offered twice daily, and water and coffee are available. S1 stated that if clients are asleep during meal times, house keeping staff with attempt to bring clients their meals to their rooms, or save them. If a meal cannot be saved, Staff will issue petty cash for the client t get something to eat at the nearby restaurant/stores. Interviews with C2-C9 Generally stated that there are 3 meals served daily, 2 snacks, and drinking water. During physical tour LPA observed the kitchen to have the minimum of perishables and non- perishable food items, Including multiple fluids.

Based on interviews, record review, and observation the Department finds that;

An exit interview was conducted, and a copy of this report provided. No citations were issued during this visit.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

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