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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608604
Report Date: 03/09/2026
Date Signed: 03/09/2026 04:47:55 PM

Document Has Been Signed on 03/09/2026 04:47 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PROMISE ASSISTED LIVING, LLC.FACILITY NUMBER:
197608604
ADMINISTRATOR/
DIRECTOR:		GREGORY Z. RESTUMFACILITY TYPE:
740
ADDRESS:1231 SOUTH ALVARADO STREETTELEPHONE:
(310) 205-2591
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY: 22CENSUS: 22DATE:
03/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Supervisor Roxana AparicioTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Supervisor Roxana Aparicio. Administrator Gregory Restum was informed via phone about today’s visit; Administrator joined visit some time after. The purpose of today’s visit was explained to supervisor Roxana Aparicio. The facility is licensed to serve 22 residents over the age of 60, of which (12) may be non-ambulatory of which 12 can be bedridden on the 1st floor only, with a hospice waiver approved for 12 residents.

The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted of the following:

FACILITY PHYSICAL PLANT
The facility is in a commercial area and is made up of a two-story building. The facility consists of the following: first floor has 10 bedrooms, 3 bathrooms, 2 closets, office space, and the kitchen; second floor has 6 bedrooms and 2 bathrooms, a front yard, a back yard, parking, and a laundry in the basement. The facility has a shaded area for residents to enjoy. There is not body of water on property.

REVIEW OF FILES
Client record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Needs and Service Plan, Personal Rights, Hospice care plan, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Operation plan, disaster and emergency plan, and infection control plan. (Report continues on page LIC-809C...)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/09/2026 04:47 PM - It Cannot Be Edited


Created By: Luis DeLeon On 03/09/2026 at 04:18 PM
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: 03/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in five bathrooms did not have the required temperature for bathroom 1-151.5F, bathroom 2-153.5 F, bathroom 3: 192.2F, bathroom 4: 151.6F and bathroom 5:129.3F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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Staff will lower water temprature and send picture to LPA by POC date. Staff will create a water log for two week and send log to LPA after two weeks of logging water temperatur for all five bathrooms.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review), the licensee did not comply with the section cited above in four (4) out of five (5) residents medication for R1-R3, and R5 are not documented as either missed or destroyed medication for residents and Medication review was not able to determine the status of medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2026
Plan of Correction
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The administrator will ensure all resident's medication once ordered by physician is given according to physician direction, and will send the staff training registration by licensed professional by POC due date. Once training completed, Administrator will send list of all staff who completed training to CCLD.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PROMISE ASSISTED LIVING, LLC.
FACILITY NUMBER: 197608604
VISIT DATE: 03/09/2026
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Observations during facility tour:
  • Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents.
  • Wall and floors are in good repair. Hallways were clean and free of obstructions.
  • Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility.
  • Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean.
  • The water temperature was tested and measured. The temperature in five (5) bathrooms were not in compliance with Title 22 regulations between 105º and 120º F degrees. The bathrooms measure in the range of 129-153 degrees F. A deficiency is noted.
  • Sharps are locked inside the kitchen room and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents.
  • Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in hallway area. Five (5) fire extinguishers were observed and were fully charged with last inspection on March 2025.
  • Last fire drill and earthquake drill were conducted on 01/19/2026.
  • The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all five (5) residents. LPA observed that four (4) out of five (5) resident medication was not properly recorded for residents R1-R3, and R5. Medication was observed that appear that had not been administered or pills on packages did not match the MAR records. Interviews with staff were not able to provide proof of destruction of missing pills or extra pills were missed or refused by residents. Staff stated that medication was distributed, but not properly documented. A deficiency is noted.
  • LPA conducted interviews with three staff and three residents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Gregory Restum.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC809 (FAS) - (06/04)
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