197608604-8-22-2022-28-AS-LHIS-CJETEK-20220919144002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 08/22/2022
Date Signed: 08/22/2022 01:24:39 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
08/16/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20220816164255

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:	08/22/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Darolyn Azevedo, Assistant Administrator		TIME COMPLETED:	01:39 PM

ALLEGATION(S):

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Insufficient staffing to meet resident needs.
Staff is not assisting resident with toileting.

INVESTIGATION FINDINGS:

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On 8/22/22 at 9:30 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint investigation to the facility. Upon arrival LPA met with S1 and explained the purpose of the visit. At 10 a.m., Assistant Administrator Darolyn Azevedo joined the investigation.

During today’s visit LPA toured the facility with S1, obtained resident roster, staff roster/ staff schedule, plan of operation, and R1 physicians’ orders. LPA interviewed residents R1 through R5. LPA Interviewed Assistant Administrator, Staff S1, S2, and S3.

Report Conintued on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20220816164255

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: 08/22/2022

NARRATIVE

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The investigation reveals the following: In regard to " Insufficient staffing to meet resident needs.", it is alleged that there is one caregiver for over 20 residents and that this staff is responsible for feeding, changing diapers and medication management for all the resident. During the visit LPA observed S1 through S3 currently working. LPA conducted file review of the plan of operation and confirmed staff need to be on site 24 hours a day, 365 days a year to supervise and provide care to residents. The facility staffing schedule revealed 2 caregivers are on site 24 hours a day. Assistant Administrator confirmed staff schedule is up to date and there are always 2 caregivers at the facility. 3/3 staff confirmed 2 caregivers are always on duty. 5/5 residents confirmed at least 2 or more caretakers are always on duty.

The investigation reveals the following: In regard to " Staff is not assisting resident with toileting ", it is alleged that that the resident urinates in a container and staff will dispose of the urine when resident is finished. If staff does not dispose of the urine in a timely manner, the resident throws the urine outside the facility on the fence. Due to staff working alone, the caregiver is not able to get to resident on time to dispose of the urine. Assistant Administrator confirm R1 throws urine outside and staff cleans it up. Assistant Administrator states R1 just started to exhibit this behavior and it maybe due to his mental status. 1/3 staff stated R1 throws his urine outside when R1 is upset with the staff. 1/3 staff stated R1 denies and forgets throwing urine outside and exhibiting a change in condition. 3/3 staff confirmed R1 do it any time R1 wants. 4/5 staff confirmed facility help residents when needed and have never heard of a resident throwing urine outside of the facility. 1/5 staff stated facility do not help whenever they call. During interview the resident denied throwing urine out of facility window.

Based on LPA's interviews, investigation revealed: 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.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC9099 (FAS) - (06/04)

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