197800441-9-25-2024-11-AS-UCOL-DA5UM5-20241017154146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800441
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:55:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/18/2024 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20240918111542

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: 79	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator - Ibrahim Zayat		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff maced client.
Staff locked client outside of the facility.
Staff caused injury to client.

INVESTIGATION FINDINGS:

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On 09/25/2024 at around 09:20 AM Licensing Program Analysts (LPA) Enriquez and Leandro conducted a complaint investigation regarding the allegation listed above. LPAs met with Administrator Ibrahim Zayat and the purpose of the visit was explained.

The investigation consisted of the following: During today’s investigation LPAs interviewed 5 out of 79 clients and 6 out of 17 staff. LPAs reviewed facility records which consisted of Personnel Report and Client Census. LPAs reviewed the records of one client.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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-20240918111542

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHEZ BON GUEST HOME	FACILITY NUMBER: 197800441
	VISIT DATE: 09/25/2024

NARRATIVE

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The investigation revealed the following: Regarding the allegations “Staff maced client”, “Staff locked client outside of the facility”, and “Staff caused injury to client.” It is being alleged that staff maced a client; physically threw the client out of the facility and locked the client out of the facility. It is being alleged that due to being maced and physically thrown out of the facility, client had an injury of a red mark on their face. Interviews conducted revealed the following: 5 out 5 clients denied all the allegations. 6 out 6 staff denied the allegations “Staff maced client.” 5 out of 6 staff denied the allegations “Staff locked client outside of the facility” and “Staff caused injury to client.” Record review revealed the following: there are no Unusual Incident/Injury Reports indicating that a client was maced, thrown of the facility and locked out. Regarding the allegations, the allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated.

No citations were issued. An exit interview was conducted, and a copy of this report was left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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