198320504-2-5-2025-11-AS-PSCT-DDLS88-20250205123844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320504
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:45:07 PM

Document Has Been Signed on 02/05/2025 12:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	CHEZ BON GUEST HOME		FACILITY NUMBER:	198320504
ADMINISTRATOR/ DIRECTOR:	SAKOFF, ARI		FACILITY TYPE:	735
ADDRESS:	1206 WALNUT AVE		TELEPHONE:	(562) 591-1411
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY: 82		CENSUS: 80	DATE:	02/05/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Ibrahim Zayat		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

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	On 02/05/25, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an announced visit to this Adult Residential Facility. LPA was greeted by Administrator, Ibrahim Zayat, and the LPA explained the purpose of today’s Pre-licensing Inspection visit. An application was submitted to CCLD on 06/05/24 for a Change of Ownership (CHOW) for an Adult Residential Facility (ARF), ages 18-59. The applicant requested a capacity of eighty-two (82) ambulatory individuals. Structure: The facility is a two (2) story building located in a residential neighborhood. The property consists of the following: 22 apartments (each apartment has 3 bedrooms, 1 living room and 1 bathroom). The common areas include a kitchen with a dining area, an outdoor back yard, an outdoor shaded area, and a laundry room. The facility also has staff offices, reception area, a medication room, and staff restrooms. Bedrooms Residents: All occupied rooms include one (1) bed, one (1) chair, one (1) night-stand, and one (1) table lamp. All bedrooms are equipped with a ceiling light and a dresser. All rooms had closets for ample storage. Each room continued smoke detectors. Report Continued On LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CHEZ BON GUEST HOME	FACILITY NUMBER: 198320504
	VISIT DATE: 02/05/2025

NARRATIVE

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Bedrooms Staff:
There is one bedroom designated for live-in staff (Room #2).

Bathrooms:
The facility has a bathroom in each room. All bathrooms have a working toilet, washbasin, and a shower.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the storage area.

Emergency Phone Numbers, Exit Plan & Menu:
The emergency disaster plan is posted along with the exit plan. A telephone line is available for the clients. The applicant has submitted a mitigation plan. Menus are posted for the clients in the courtyard.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked cabinet. Food supply is adequately stored in kitchen cabinets and consists of can and other dry goods.

Smoke Detectors/Fire Extinguishers:
Smoke/carbon monoxide detectors were operable. The call system was centralized and operable. All fire extinguishers were fully charged and last inspected on 10/16/24.

Toxins, Laundry, & Kitchen:
All toxins are locked and stored in the laundry area and kitchen.
Stove burners, oven, and microwave are working. There are several refrigerators and freezers in the kitchen. The facility has a working laundry room.

Water Temperature:
The water temperature measured between 105.6F and 115.4F degrees throughout the facility.

Medications, First-Aid Kit & Book:
First aid kits and manuals are stored in the locked medication room. Each kit has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The client's medications are stored in the medication room and are inaccessible to clients.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CHEZ BON GUEST HOME	FACILITY NUMBER: 198320504
	VISIT DATE: 02/05/2025

NARRATIVE

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Resident & Staff Files:
The applicant will be handling the cash resources for the clients. Records of staff and clients will be stored in a locked cabinet in the administrator’s office.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the clients use and are stored in the activity room.

Pool:
The facility does not have a pool.

Fire clearance:
A Fire Clearance inspection was conducted on 08/13/2024 and approved for a capacity of eighty-two (82) ambulatory clients.

Component III:
LPA and the applicant completed the Component III PowerPoint presentation, which gives an overview of what to expect while running an Adult Residential Facility.

During the Pre-licensing inspection visit, the department did not observe any deficiencies.

An exit interview was conducted, and a copy of this Facility Evaluation Report has been furnished to the Administrator, Ibrahim Zayat.

The department will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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