197608604-8-8-2024-28-AS-LHIS-D7YMMA-20240809094333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 08/08/2024
Date Signed: 08/08/2024 11:56:33 AM

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
06/06/2024 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240606093952

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:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Daroly Azevedo		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff member physically assaulted resident which resulted in an injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator, Darolyn Azevedo who assisted with the visit.

Regarding the allegation that : Staff member physically assaulted resident which resulted in an injury. The investigation consisted of interview(s) with Staff #1 - Staff #3, and resident #1 - resident #4. LPA also reviewed resident #5's file.

The investigation revealed that former resident, (resident #5) alleged that staff #4 hit her. Staff interviewed stated that resident #5 made this allegation sometime in December of 2023. Three out of three staff interviewed denied that they have observed any staff assault any residents in care. Staff interviewed stated that the facility conducted an internal investigation, and staff #4 denied the allegation. Staff interviewed stated that there were no witnesses to resident #5's allegation. Staff #4 is no longer working at the facility, therefore LPA was unable to interview Staff #4.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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-20240606093952

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: 08/08/2024

NARRATIVE

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Resident #5 is no longer living at the facility, and was not interviewed. Residents interviewed were unable to corroborate the allegation. Resident #1 - Resident #4 stated that they have not observed any staff assault any residents in care.

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, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

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