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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608604
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:53:28 PM

Substantiated


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
01/11/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230111151623
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
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Titiarish Fields- Caregiver TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility is malodorous.
Facility is unsanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA Flores met with Titiarish Fields Caregiver and explained the reason for the visit.

The investigation consisted of the following: LPA Flores conducted a tour of the facility with Titiarish Fields caregiver and observed the following resident rooms #1(RR1),2(RR2),4(RR4),5(RR5),7(RR7),9(RR9),10(RR10),11(RR11),13(RR13),14(RR14),15(RR15),16(RR16),19(RR19),21(RR21), bathroom #1(BR1),#2(BR2),#3(BR3), #4(BR4),#5(BR5), and common areas. LPA interview resident #1(R1) and #2(R2), staff #2(S2), #3(S3), and administrator over the phone. LPA requested copies of insurance's assessment and services to be email to LPA.

The investigation revealed the following: Regarding allegation: Facility is in disrepair. It is alleged resident bedroom's ceiling has a hole and water dripped into one of the resident bed, resident was in bed when the crack occurred. Interviews with residents revealed 2 out of 2 residents stated (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20230111151623
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: 01/13/2023
NARRATIVE
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the ceiling and water leak happened around the time it rain, residents were unable to remember the day and stated the water dripped next to them and not in their beds or on them. Interviews with 2 out of 2 staff revealed the water damage around the facility was observed right after the rain by Monday 1/9/23. Administrator stated insurance company has been contacted and conducted an assessment of the damage and will take care of the repairs. LPA observed the following during the facility's tour RR2 has a hole in the ceiling of about 2x1 foot long in the center against the back wall of the room, a water repair was notice that has been previously repair to the right of the hole. RR9 and RR10 is a shared room, a hole in the ceiling of about 3x2 feet long was observed about 3 feet from the right corner wall and above the window where R2's bed is located. Wall in hallway to the left of French door leading outside was observed with paint wrinkle and peel of about 2x1 foot long of water damage, and ceiling in medication room was observed with a bubble of about 2x2 feet long right above where medication is stored.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding allegation: Facility is malodorous. It is alleged bad smells are present in the facility. Interviews with residents revealed 2 out of 2 residents stated not to notice bad smells. Interviews with staff revealed 2 out of 2 staff stated there are no bad smells or mildew smell. During facility's tour LPA identify moldy smell upon entering the facility, by the office area, bowel movement smell coming from RR1 notice by the hallway and stronger once entering RR1, and in RR15 and RR16 shared room a distinctive bad smell.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding allegation: Facility is unsanitary. It is alleged signs of mildew are present. Interviews with residents revealed 1 out of 2 residents has not observed mold or mildew at the facility. 1 out of 2 residents was unable to answer due to cognitive skills. 2 out of 2 staff have not observed mold or mildew in the facility. During facility's tour LPA observed mildew under resident's wardrobe next to resident's refrigerator in RR7. Floor in RR2 was observed with debris and overgrow dirt stains.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.
Exit interview was conducted with Titiarish Fields Caregiver and a copy of this report, LIC 9099D, and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20230111151623
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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidence by:
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Administrator will email pictures of temporary tarp place on balcony roofs above RR2 and RR9/10 by end of day of1/13/23 and will send pictures of repairs done to the ceilings, wall, and roof by POC due date 1/20/23 to the department.
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Based on observation licensee failed to ensure RR2 and RR9 and RR10, common hallway, and medicaiton room were free of holes and/or water damage which poses a potential health, safety, or personal rights risk to the persons in care.
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Type B
01/20/2023
Section Cited
CCR
87303(a)(1)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance ...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidence by:
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Administrator will conduct the proper repairs to remove mildew in flooring of RR7 and will ensure there is no mold/mildew throughout the facility and will ensure facility is free of smells will submit service receipt to the department by POC due date 1/20/23.
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Based on observation licensee failed to ensure facility is free of mildew and smells which poses a potential health, safety, or personal rights risk to the persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3