197608604-1-16-2024-28-AS-LHIS-CZKL3H-20240117072354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 01/16/2024
Date Signed: 01/16/2024 01:31:31 PM

Unsubstantiated

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
09/13/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220913140148

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: 21	DATE:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Roxana Aparicio, Supervisor		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff are not adequately supervising resident resulting in resident sustaining multiple fractures.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the investigation conducted by DSS Investigation Branch (IB) Investigator Laura Garcia. LPA explained the purpose of the visit to Supervisor Roxana Aparicio.

The investigation consisted of: On 9/4/22, LPA Galarza conducted a physical tour of the facility and file review was conducted. No staff or residents were interviewed. Resident (R1's) file documents [Identification and Emergency Information, Admission Agreement, Physician's Report (3/19/2021), incomplete Oceanside Home Health Services, Inc documents (7/27/22), Preplacement Appraisal Information, Resident Appraisal, Centrally Stored Medication Record/Medication Administration Recors (Aug. 2022- Sep. 2022), three (3) incident reports dated 7/8/22, 9/4/22, 9/8/22, Admission Policies, Procedure & Care of Persons with Dementia, LIC 500 Personnel Report, and Register of Facility Residents were obtained. IB investigator obtained medical records, and conducted interviews.

***Narrative continues next page.*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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-20220913140148

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: 01/16/2024

NARRATIVE

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Allegation: Staff are not adequately supervising resident resulting in resident sustaining multiple fractures. It is alleged that resident (R1) has had repeated falls at the facility resulting in multiple fractures. Per record review, on June 8, 2022, resident (R1) fell on their face when getting out of bed. The facility called R1's physician and 911. The resident was transported to Good Samaritan Hospital, and was admitted with a nasal fracture. On 9/4/2022, R1 fell as they were trying to get up. The resident was examined that evening by Primary Care Physician, who determined that the resident did not need to go to the hospital. Staff were instructed to monitor the resident. Home health services were already being provided R1 to address General Muscle Weakness. The resident is ambulatory, uses a wheelchair to ambulate around the facility, and does not require one-to-one assist.

On 9/8/2022, the resident reported to staff that they were having pain on the side of the body they fell on. Facility staff notified R1's Primary Care Physician, and per MD note it states that staff were informed that the physician would exam the resident that evening, but staff called 911. According to staff interviews, facility protocol is to to immediately send out residents to the hospital for an evaluation when they sustain a fall, or get injured. On 9/8/2022, R1 was admitted to LAC/USC Medical Center with a left hip fracture. Based on interviews conducted, all staff, residents, and 3rd party providers interviewed denied the allegation. Resident (R1's) physician's office stated that the facility has great communication, and appear to be attentive to residents' needs. Based on the above information and documentation provided there is insufficient evidence to corroborate negligence or lack of care on behalf of facility staff.

Based on interviews conducted and record(s) review, there was insufficient evidence to prove the allegation. 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.

Exit interview was conducted with Roxana Aparicio. A copy of the report will be emailed due to printing issues.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

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