197608604-5-25-2021-28-AS-FFIS-CRRUSS-20230512155050

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 05/25/2021
Date Signed: 05/25/2021 03:05:29 PM

Substantiated

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
05/20/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210520110651

FACILITY NAME:	PROMISE ASSISTED LIVING, LLC.		FACILITY NUMBER:	197608604
ADMINISTRATOR:	GREGORY Z. RESTUM		FACILITY TYPE:	740
ADDRESS:	1231 SOUTH ALVARADO STREET		TELEPHONE:	(310) 205-2591
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	22	CENSUS: 18	DATE:	05/25/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Assistant Administrator / Darolyn "Dee" Azevedo		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff failed to supervise resident resulting in resident wandering away from facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Supervisor / Roxana Aparicio and were later joined by the Assistant Administrator / Darolyn "Dee" Azevedo who assisted with the visit. LPA explained the purpose of today’s visit is to discuss the above mentioned allegation.

During today's visit, LPAs interviewed the Assistant Administrator / Darolyn "Dee" Azevedo, staff #1-#4 (S1-S4) and Resident #2-#3(R2-R3). LPA unable to interview Resident #1 (R1) as R1 is no longer in the facility. LPA also reviewed the file of R1 and obtained copies of the following documents; -Identification and Emergency Information, -Physician's Report, -Resident Appraisal, -Preplacement Appraisal Information, -Admission Agreement and -Unusual Incident/Injury Report dated: 5/2/21.

The investigation revealed the following...

Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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 5

Control Number 28-AS-20210520110651

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: PROMISE ASSISTED LIVING, LLC.	FACILITY NUMBER: 197608604
	VISIT DATE: 05/25/2021

NARRATIVE

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In regards to the allegation "Staff failed to supervise resident resulting in resident wandering away from facility" it was alleged that the facility staff did not supervise R1 enough which resulted in R1 leaving the facility and going missing. Review of R1's document reveal that R1 has a medical diagnosis that requires staff supervise and monitor R1. Interviews with staff show that on 5/2/21 R1 left the facility without the knowledge of staff and did not return. On 5/8/21 R1 was admitted to Lakewood Regional Hospital and would not be returning to this facility. LPA confirmed that R1 was admitted on 5/8/21 and released to a skilled nursing facility on 5/12/21. From this investigation it was revealed that staff failed to provide supervision to R1 resulting in R1 wandering away from the facility and being admitted into a hospital. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210520110651

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: PROMISE ASSISTED LIVING, LLC.	FACILITY NUMBER: 197608604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/04/2021 Section Cited CCR 87101(c)(3)(F)	1 2 3 4 5 6 7	87101 Definitions(3)"Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents....	1 2 3 4 5 6 7	Faciltiy to provide in service training to staff on the importance of supervision and monitoring of residents in the faciltiy. Training Sign in sheet to be provided to LPA by POC Due date.
	8 9 10 11 12 13 14	"Care and Supervision" shall include, but not be limited to...:(F) Supervision of resident schedules and activities; This was not met as evidenced by R1 leaving the facility and going missing without the knowledge of staff. This poses a potential health and safety risk to residents in care and supervision.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
05/20/2021 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210520110651

FACILITY NAME:	PROMISE ASSISTED LIVING, LLC.		FACILITY NUMBER:	197608604
ADMINISTRATOR:	GREGORY Z. RESTUM		FACILITY TYPE:	740
ADDRESS:	1231 SOUTH ALVARADO STREET		TELEPHONE:	(310) 205-2591
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90006
CAPACITY:	22	CENSUS: 18	DATE:	05/25/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Assistant Administrator / Darolyn "Dee" Azevedo		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Failure to notify resident’s immediate family member of missing resident

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210520110651

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: PROMISE ASSISTED LIVING, LLC.	FACILITY NUMBER: 197608604
	VISIT DATE: 05/25/2021

NARRATIVE

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(5) of (5) staff interviewed deny the allegation. (2) of (2) residents interviewed could not corroborate the allegation. Documents from R1's file show that R1 does not have an emergency contact information of any family member on file. R1's file shows that R1 is responsible for themselves as well. interviews conducted do show that Assistant Administrator Darolyn "Dee" Azevedo did contact a family member of R1 on 5/5/21 to notify of the incident even though R1's files do not show that family members information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Assistant Administrator / Darolyn "Dee" Azevedo and a hard copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021

LIC9099 (FAS) - (06/04)

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