197608604-4-28-2023-28-AS-MGFS-CRBRZM-20230428132810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608604
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:28:28 PM

Document Has Been Signed on 04/28/2023 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 20	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Titiarish Fields - Caregiver		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Titiarish Fields caregiver and explained the reason for the visit. D'arolyn Acevedo arrived 20 minutes later. The facility is licensed to serve 22 residents over the age of 60, of which (12) may be non-ambulatory and/or 12 may be bedridden in the 1st floor only, with a hospice waiver approved for 12 residents. The home is a two story building located in residential/commercial area and consist of the following; first floor has 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen; second floor has 8 bedrooms and 2 bathrooms, a front yard, a back yard, parking, and a laundry in the basement. LPA conducted a tour with Titiarish Fields and observed the following: Kitchen consist of a commercial stove/grill, sink, a pantry, refrigerator, and freezer inaccessible to the residents. LPA observed sufficient food. Kitchen and pantry floors were observed dirty during the visit. Each bathroom was observed with skid mats and grab bars and water temperature was tested as follow; bathroom #1(B1) tested at 157.9 degrees F., bathroom #2(B2) tested at 136.0 degrees F., bathroom #3(B3) tested at 141.4 degrees F., bathroom #4(B4) tested at 89.4 degrees F., and bathroom #5(B5) tested at 155.1 degrees F., which is not within the required 105-120 degrees F. LPA observed 5 resident rooms (room #1,#2,#5,#21,#2) and observed required furniture, bedding supplies, and sufficient lighting. Resident in room #1 was observed to have full bed rails and has a hospice plan and bed rail request on file. Front and back yard have shaded sitting area. No large bodies of water were observed. LPA reviewed medication and files for 5 residents and 5 staff files. Medication for Resident #1(R1) was stored in plastic bag and bottle was disposed. Administrator certificate was observed for Gregory Restum #600 exp. date: 4/3/23. PUB 745 was not observed posted and LIC 610D needs to be update to current version. Last fire drill was provided on 4/3/23. Facility has fire sprinkler system and smoke/carbon monoxide detectors throughout. Fire extinguishers were observed and last checked in Jan. 2023. Deficiencies were noted on LIC 809D per Title 22 regulations. Exit interview was conducted with D'arolyn Acevedo and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2023 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in B1 tested at 157.9 degrees F., B2 tested at 136.0 degrees F., B3 tested at 141.4 degrees F., B4 tested at 89.4 degrees F., and B5 tested at 155.1 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2023
	Plan of Correction
1 2 3 4	Lincensee will ensure that water heater is at the required 105-120 degrees at all times and will certify via LIC 9098 by POC due date 4/29/23. Facility will maintain a water temperature log for the next 7 days and submitted to the department by 5/5/23.

Type A

Section Cited

CCR

87465(h)(5)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 5 medicaitons reviewed, R1's medication was stored in plastic bag not in original container which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2023
	Plan of Correction
1 2 3 4	Licensee will provide in-service training on section 87465 to staff and will send a copy of training and signing log to the depatment by POC due date 4/29/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 04/28/2023 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in kitchen and pantry's floor were observed dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Administrator will provide in-service training on section 87555 to kitchen staff and will ensure kitchen floor's are maintain clean at all times, will submit in-service training and pictures of clean floors to the department by POC due date 5/5/23.

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in LIC 610D and emergency disaster plan reviewed was not the current version which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Administrator will updated LIC610D and will submit a copy to the department by 5/5/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

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