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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:26:52 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
06/23/2022 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220623160200
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:
03/07/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Roxanne AparicioTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff caused a resident to fall while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Angelica Rea and Christian Gutierrez conducted an unnannounced visit. LPA's met with supervisor caregiver, Roxanne Aparicio, who assisted with today's visit. The reason for the visit is to correct the date from 2/21/24 to 2/22/24 and that the findings and all other information remain the same.

Regarding the allegation that Staff #1 caused resident #1 to fall while in care. An initial visit was conducted on 6/29/22. The investigation consisted of Interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5. Administrator and staff interviewed stated that they were not aware of the incident. Residents interviewed were not able to corroborate the allegation. Resident #1 denied that Staff #1 caused her to fall.

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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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
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
06/23/2022 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220623160200

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:
03/07/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Roxanne AparicioTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Staff did not seek timely medical attention for a resident
Resident is providing care and supervision to another resident
Staff did not properly report an incident involving a resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Angelica Rea and Christian Gutierrez conducted an unnannounced visit. LPA's met with supervisor caregiver, Roxanne Aparicio, who assisted with today's visit. The reason for the visit is to correct the date from 2/21/24 to 2/22/24 and that the findings and all other information remain the same.

Regarding the allegation(s) that : Staff did not seek timely medical attention for resident #1, Resident is providing care and supervision to resident #1, and staff did not properly report an incident involving resident #1. An initial visit was conducted on 6/29/22. The invesitgation consisted of interview(s) with Administrator, Staff #1 - Staff #4, and Resident #1 - Resident #5.

The investigation revealed the following : Regarding the allegation that : Resident is providing care and supervision to resident #1. Resident #1 stated that on 6/21/22, she had a fall in the bathroom while being assisted by staff #1. Resident #1 stated that staff #1 was not able to help her get back up, and staff #1 asked resident #2 to assist resident #1 in getting up.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220623160200
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: 03/07/2024
NARRATIVE
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Resident #1 stated that she was not dressed at the time of the incident. Residents interviewed corroborated the allegation(s). Resident #2 stated that he did assist resident #1 on 6/21/22. Resident #3 stated that he witnessed the incident. Resident #4 and Resident #5 were not aware of the incident. Staff interviewed stated that they were not present at the time of the incident, and did not know if it happened.

Regarding the allegation that : Staff did not seek timely medical attention for a resident, Resident #1 stated that she did not receive medical attention following the incident. Resident #1 stated that staff #1 stated that resident did not need medical assistance. Staff interviewed stated that they were not present at the time of the incident, or stated that they were not aware of the incident occurring. Staff #1 stated that she did not recall the incident. Residents interviewed were able to corroborate the allegation. Three out of five residents interviewed stated that resident #1 did not receive medical attention after the fall.

Regarding the allegation that : Facility did not report the incident to Community Care Licensing as required. LPA observed that the facility did not have an incident report regarding the incident that occurred on 6/21/22, and did not send a report to Community Care Licensing as required.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted, and copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220623160200
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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87468.1(a)(1)
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a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents personal rights are not being violated. Administrator will conduct an in service training with all staff on resident personal rights and will send proof of staff training to LPA by POC due date.
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This requirement is not being met as evidenced by: LPA learned that resident #1 was assisted by resident #2 in the bathroom while resident #1 was not dressed.
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Type B
03/08/2024
Section Cited
CCR
87465(a)(1)
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a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental car
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Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents who require a medical assessment receive it as required. Administrator will send LPA facility plan on incidental medical and dental care, and proof of staff training on plan by POC due date.
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This requirement is not being met as evidenced by: LPA learned that resident #1 was not sent out to be medically assessed after falling on 6/21/22.
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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: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220623160200
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: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87211(a)(1)(D)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Administrator will ensure that Title 22 regulations are being adhered to as required. Administrator will conduct an inservice training with all staff on reporting requirements and will send proof of training to LPA by POC due date.
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This requirement is not being met as evidenced by : LPA observed that facility did not submit a special incident report for resident #1's fall on 6/21/22.
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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: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5