197608604-5-5-2023-28-AS-FFIS-CRRUSQ-20230512155043

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:26:03 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: 22	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Staff Brian Lopez		TIME COMPLETED:	03:00 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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***This report supercedes previous report dated 5/25/21. LPA to change the previous citation to the correct one that will be on this report. No changes are being to the details****

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA met with Staff Brian Lopez assisted with the visit. LPA explained the purpose of today’s visit i

Initial visit was conducted on 5/25/21 and LPA conducted the following: LPA 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.
\
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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 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: 05/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411.Personnel Requirements-General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This was not met as evidenced by:	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 was provided to LPA by oringial POC Due date. 6/4/21. penl POC is cleared at time of visit. Civil Penalty Assessed
	8 9 10 11 12 13 14	Facility staff was not aware of R1 walking out of the facility. R1 was not supervised by staff. According to files, R1 is not able to leave the facility unassisted. This poses an immediate Health and Safety risk for 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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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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: 05/05/2023

NARRATIVE

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The investigation revealed the following: 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 immediate Civil Penalty of $500.00 is being issued today, due to the lack of supervision resulting in R1 leaving the facility and being hospitalized. Refer to LIC 421IM* Facility was informed that a civil penalty may be assessed based on health and safety code 1569.49 (e)or (f), or 1548 (e) or (f), 1568.0822(e) or (f)."

An exit interview was conducted. Appeal rights were provided and discussed. A copy of this report was provided as well.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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