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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608604
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:12:28 PM

Document Has Been Signed on 09/14/2022 12:12 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
CCLD Regional Office, 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:
09/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:D'arolyn Azevedo, Administrative AssistantTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza made an unannounced visit for the purpose of an unrelated complaint investigation control # 28-AS-20220913140148. LPA met with Administrator Gregory Restum and Administrative Assistant D'arolyn Azevedo and explained the purpose of this report.

During today's 24-hour health & safety complaint visit a physical plant tour was completed, and physical plant deficiencies were observed.

OBSERVATIONS:

  • The majority of resident room windows had sheer fabric curtains that do not afford privacy during day and nighttime hours.
  • Resident beds had mattress protector covers, but no mattress pads as required per Title 22 87307 Personal Accommodations and Services.


Deficiencies were cited per California Code of Regulation Title 22, Division 6, Chapter 8. See LIC809-D.

Exit interview held with Administrative Assistant D'arolyn Azevedo. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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 09/14/2022 12:12 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/14/2022 at 11:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met by evidence of:
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Administrator shall ensure all residents shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

Submit proof of purchase/corrections, and a wrtiten statement indicating which rooms had new curtains installed.
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Based on observation, LPA observed that the majority of resident rooms with windows had sheer curtains that were see through; not providing resident's privacy during day and night hours; which poses a potential health and safety risk to clients in care.
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Type B
09/28/2022
Section Cited
CCR87307(a)(3)(C)

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87307(a)(3)(C) Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.....

This requirement was not met by evidence of:
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Administrator agreed to ensure that all resident beds have mattress pads, and sheets at all times.

Submit proof of purchase receipt and pictures by POC due date.
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Based on physical plant observations none of the resident beds had mattress pads; they only had plastic bed protectors; which poses poses a potential health and safety risk.
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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
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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