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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:41:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/22/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230322120637
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: 22DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Darolyn Azevedo - Administrative AssistantTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Facility does not have adequate staff to meet the needs of the residents.
Facility is in disrepair.
Facility staff did not ensure that residents had hot water.
Facility staff did not meet resident's diapering needs.
Facility staff did not ensure that residents received showers.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Darolyn Azevedo (Administrative Assistant) and explained the reason for the visit.

The investigation consisted of the following: On 03/27/23, LPA obtained copies of the resident and staff rosters, interviewed Administrative Assistant, Resident 1 - Resident 3 (R1 - R3) and toured the facility. LPA also obtained copies of estimate documents for roof and bathroom ceiling repair. Today's visit, LPA obtained copies of resident and staff rosters,and interviewed Administrative Assistant, Staff 1 - Staff 3 (S1 - S3), Resident 4 - Resident 7 (R4 - R7) and toured the facility.

The investigation revealed the following: regarding the allegation "facility does not have adequate staff to meet the needs of the residents", it is alleged that on 03/18/23 during the night shift, there was a storm flood inside the facility and a staff was working alone and had to clean up the flood while also having to care for the 22 residents. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 2
Control Number 28-AS-20230322120637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PROMISE ASSISTED LIVING, LLC.
FACILITY NUMBER: 197608604
VISIT DATE: 11/02/2023
NARRATIVE
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Review of facility's clock in time sheet, on 03/18/23 there were 2 staff working during the night shift (2pm-10pm) and 1 staff working the graveyard shift (10pm-6am). Per Title 22 Section 87415(a)(3), the following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available as indicated below to assist in caring for residents in the event of an emergency: In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. Staff 1 (S1) is the supervisor and the staff on call. Administrative Assistant and staff interviewed denied the allegation. They stated there was no flood and that they have adequate staff to meet the residents' needs. Residents interviewed could not corroborate the allegation and stated their needs are being met.

Regarding the allegations "facility is in disrepair", "facility staff did not ensure that residents had hot water", and "facility staff did not ensure that residents received showers", it is alleged that the storm caused damage to the water heaters and therefore there was no hot water for the residents to shower for a couple of days (03/18/23 - 03/21/23). Administrative Assistant and staff interviewed denied the allegation. They stated that there was no flood. According to the Administrative Assistant the water heaters were replaced due to wear and tear and not because they were damaged. They replaced them 1 at a time between 03/19/23 and 03/20/23. Residents interviewed could not corroborate the allegations. They expressed no issues with showering or not having hot water during the dates above. During the facility tour on 03/27/23, LPA observed new water heaters and LPA measured the water temperature and it measured within the required 105-120 degrees F.

Regarding the allegations "facility staff did not meet resident's diapering needs", it is alleged that a resident obtained an infection due to not having their diaper changed. No information of this resident was provided to the LPA. Administrative Assistant and staff interviewed denied the allegation. They stated that there was no resident that got an infection. Residents interviewed could not corroborate the allegation. The residents that get assistance with diaper change expressed no issues.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2