<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608604
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:54:53 PM


Document Has Been Signed on 01/13/2023 12:54 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. RESTUMFACILITY TYPE:
740
ADDRESS:1231 SOUTH ALVARADO STREETTELEPHONE:
(310) 205-2591
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:22CENSUS: 22DATE:
01/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Titiarish Fields - Caregiver TIME COMPLETED:
01:15 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 a case management deficiencies visit during a complaint investigation visit due to observed deficiencies. LPA met with Titiarish Fields caregiver and explained the reason for the deficiencies.

On 1/13/23 LPA conducted a complaint investigation visit, during the visit LPA conducted a tour of the facility and observed the following deficiencies.

Bathroom #1(BR1) had an out of order sign, upon entering the bathroom toilet was observed with water overflow and caregiver explained the toilet was clogged and needed repair. Water temperature was tested and tested at 117.2 degrees F. Bathroom #2(BR2) water temperature tested at 122.5 degrees F. Bathroom #3(BR3) water temperature tested at 138.0 degrees F. Bathroom #4(BR4) water temperature tested at 65.4 degrees F. Bathroom #5(BR5) water temperature tested at 156.3 degrees F. which is not within the required 105 - 120 degrees F.
Resident room #5 (RR5) was observed and wardrobe was observed to have front left and right back legs broken and leaning against the wall, resident stated the door does not lock, upon caregiver closing the door with lock on tested the door and open it, showing lock is not working.
Flooring in bathroom #5(BR5), resident room #15 and #16 (RR15/16), resident room #9 and #10 (RR9/10), outside room #1(RR1) and office area is peeling, lifted and/or broken.
Exit door to the parking area and outdoor by the stairs leading to the office and kitchen area has a metal cover lifted and sticking out.

Deficiencies have been noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8.

Exit interview was conducted with Titiarish Fields Caregiver and a copy of this report, LIC 809D,and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/13/2023 12:54 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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2023
Section Cited

1
2
3
4
5
6
7
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care...shall be maintained... not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will certify on LIC 9098 to ensure that water temperature is maintain within the required 105-120 degrees F. by POC due date1/14/23.
8
9
10
11
12
13
14
Based on observation licensee failed to ensure water temperature in BR2,BR3,B#4,And BR5 is maintained within the required 105-120 degrees which is an immediated health, safety, or personal rights risk to the persons in care.
*Civil Penalites have been asses for a repeated violation*
8
9
10
11
12
13
14
Type B
01/20/2023
Section Cited

1
2
3
4
5
6
7
87303 Personal Accomodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will submit pictures of repairs of flooring, BR1,and RR5 to the department by POC due date 1/20/23.
8
9
10
11
12
13
14
Based on observatiosn licensee failed to ensure facility's flooring, BR1, and RR5 wardrobe and door lock is in good repair which poses a potential risk to the health, safety, or personal rights of persons in care.
8
9
10
11
12
13
14
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2