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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608604
Report Date: 03/08/2022
Date Signed: 03/08/2022 01:38:45 PM


Document Has Been Signed on 03/08/2022 01:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:PROMISE ASSISTED LIVING, LLC.FACILITY NUMBER:
197608604
ADMINISTRATOR:GREGORY Z. RESTUMFACILITY TYPE:
740
ADDRESS:1231 SOUTH ALVARADO STREETTELEPHONE:
(310) 205-2591
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:22CENSUS: 21DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gregory Restum, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and met with the Administrator, Gregory Restum. The purpose of the visit was explained. The facility is licensed for a capacity of 22 individuals, of which 12 may be non-ambulatory or 12 bedridden (1st floor only). The hospice waiver is approved for 12 residents.

LPA toured the 2-story facility with the house supervisor. The following was observed:
* The first floor consists of 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen. The second floor consists of 8 bedrooms and 2 bathrooms. The backyard consists of tables and chairs with shades. There are no items obstructing the passageways. The residents' rooms have the required furniture. LPA observed signage posted at the front entrance and around the facility and bathrooms. LPA recommended to add additional signage such as sneeze/cough etiquette in the dining room. Temperature is taken for visitors upon entering and logged. LPA recommended to continue the covid-19 screening questionnaire while taking their temperature. Per Staff, they are checking residents' temperature every shift. They are also cleaning and disinfecting highly touched surfaces on every shift. Food supplies for 2 day perishable and a week of non-perishable are also observed. Knives, cleaning solutions, and disinfectants are stored and locked making them inaccessible to clients. LPA tested the hot water temperature in all the communal use bathrooms and the bathroom between room #18 and #19 measured at 143 degree Fahrenheit, which is over the required range of 105 - 120 degrees F. Smoke detectors are hard wired and located in each room and a carbon monoxide detector is located on each floor. 3 Staff files reviewed have the health screening form and TB test results. The medications are centrally stored and locked. LPA reviewed medications for 5 residents and found discrepancies in 4 out of the 5 medications.

LPA provided a technical advisory for the N95 Fit Testing.
Deficiencies were documented on the LIC809D. An exit interview was conducted and a copy of this report along with appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 03/08/2022 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PROMISE ASSISTED LIVING, LLC.
FACILITY NUMBER: 197608604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above in 4 out of 5 residents' medications reviewed and observed Resident #1 was not given the Respiridone 2MG and for Residents #3 - 5, all the medications observed were not indicated on the MAR log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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The Administrator shall review the Physician's Order for all the residents taking medication to ensure that they are being given medication as prescribed. The Administrator shall conduct a medication training for all staff handling medication and submit proof of training log to LPA by POC due date 3/9/22.
Type A
Section Cited
CCR
87465(i)
87465
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not comply with the section cited above in 4 out of 5 residents' medications where Staff could not indicate if the medication observed in their boxes were discontinued by the physician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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The Administrator shall follow up with residents' medications to ensure they are not discontinued by the physician. An in-service training for medication shall be conducted to ensure residents are taking their medication as ordered by the physician and proof shall be provided to the LPA by POC due date 3/9/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/08/2022 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PROMISE ASSISTED LIVING, LLC.
FACILITY NUMBER: 197608604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with regulation cited above where the hot water temperature measured at 143 degree F for the bathroom upstairs between rooms #18 and room #19, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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The Administrator shall adjust the hot water setting and ensure that the hot water temperature is maintained between the range of 105 - 120 degree F. The log shall be submitted to LPA by POC due date 3/9/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4