197608604-5-30-2023-28-AS-LHIS-CYJN5C-20231215090920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:31:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/23/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230523144539

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: 22	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Gregory Restum, Administrator and Roxane Aparicio		TIME COMPLETED:	03:44 PM

ALLEGATION(S):

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Uncleared staff caring and supervising residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Gregory Restum (Administrator) and Darolyn Azevedo (Administrative Assistant) and explained the reason for the visit. Roxane Aparicio also assisted with the visit and signed report.

The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, Reviewed all staff files and obtained background clearance and association to facility documentation. LPA Interviewed 6 staff S1 - S6 and Six Residents R1-R6.

The investigation revealed that all staff had background Clearance and are were associated to facility before they began working at the facility. Six of Six staff stated that they had live scan prior to starting work at facility. Six of Six residents could not collaborate the allegation and stated they would not know since that

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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

Control Number 28-AS-20230523144539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/30/2023

NARRATIVE

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(Continued from 9099)

information is not shared with them. LPA obtained documentation that all staff had undergone background checks and associated to facility before staff began working at facility.

Based on LPA interviews and file review, the 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) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
05/23/2023 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20230523144539

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: 22	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Gregory Restum, Administrator and Roxane		TIME COMPLETED:	03:44 PM

ALLEGATION(S):

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Staff do not meet training requirements.

INVESTIGATION FINDINGS:

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Regarding the allegation: Staff do not meet training requirements. It is alleged that staff do not meet the training requirements and lack current CPR training.

The investigation consisted of interviews with six staff S1-S6 and six residents R1-R6. LPA reviewed all staff files including Staff S#6 who is the most current employee and works overnight shift. Six of Six staff all stated that they are trained prior to starting their new positions and all staff had current CPR first aid certification on file as well as other training certificates. Six of Six residents they are not sure of training of staff and several residents stated they feel comfortable with the new overnight staff. Several residents stated that overnight staff is very nice and comes around to check on residents during the night. LPA reviewed and obtained a copy of facilities emergency disaster plan and it was out dated (01/20/20) and did not have S6 listed as responsible staff during overnight hours. S6 stated he did not remember where gas shut off valve was located and did not remember if he was trained on that. Administrator stated that S6 is 18 years old and does not retain information very well. (CONTINUED ON 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230523144539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/30/2023

NARRATIVE

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(CONTINUED FROM 9099)

Facility last emergency drill was on 04/01/2023 and did not include S6 who didn't' start work until 05/22/2023 and there was no documentation that S6 had undergone Emergency Disaster training and Emergency Disaster Plan does not include S6 who is the only overnight staff at this time. This poses a health and safety hazard to the residents in care.

Based on interviews, file review and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Civil penalties assessed. Repeat violation in last twelve months,

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230523144539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 06/06/2023 Section Cited HSC 1569.695(a)	1 2 3 4 5 6 7	(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 the following: This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide emergency disaster training to S6 and will updated LIC610D and will submit a copy to the department by 6/6/23.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not comply with the section cited above in LIC 610D and emergency disaster plan reviewed was not the currently updated to include S6 who is the sole staff during the overnight shift 10PM -6PM which poses/posed a potential health, safety or personal rights risk to persons in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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