331800003-6-15-2020-18-AS-RLAY-BQNLP4-20200617085516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 06/11/2020
Date Signed: 06/15/2020 10:22:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2019 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20190927133717

FACILITY NAME:	AZZUR ASSISTED LIVING LLC		FACILITY NUMBER:	331800003
ADMINISTRATOR:	RADWAN BYRON GONZALO		FACILITY TYPE:	740
ADDRESS:	397 E MAIN STREET		TELEPHONE:	(951) 665-6240
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92583
CAPACITY:	24	CENSUS: 22	DATE:	06/11/2020
		UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Mary Jane Tolentino, Licensee		TIME COMPLETED:	10:18 AM

ALLEGATION(S):

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Staff failed to address resident's change in medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility and spoke with Licensee, Mary Jane Tolentino, via telephone call to deliver the findings of the investigation on the above allegation.

Pertaining to the allegation, "Staff failed to address resident's change in medical condition," it was alleged Resident One's (R1's) medical decisions were being made by facility staff and/or themself, despite being diagnosed with a cognitive disease. The LPA, on 10/03/2019, initiated the investigation into the above allegation; staff/resident interviews were conducted, records were reviewed, and copies of pertinent information were obtained. According to R1's Medical Assessment, R1 was diagnosed with a cognitive disease on 03/14/2018. The Medical Assessment also indicated R1 could not manage their own treatment. The LPA interviewed R1 who reported no one has made medical decisions for them while residing at the facility. R1 reported not having to make any medical decisions while residing at the facility. Licensee Tolentino was also interviewed and reported R1 does not show symptoms commonly associated with the cognitive disease. She reported R1 does not have a responsible party, R1 makes their own medical decisions, and she denied making

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20190927133717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AZZUR ASSISTED LIVING LLC	FACILITY NUMBER: 331800003
	VISIT DATE: 06/11/2020

NARRATIVE

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medical decisions for the resident. The Licensee reported she did not refer R1 to a third party agency to be involved in medical decision making for the resident. From the evidence collected, no information obtained could corroborate or refute the allegation that R1 and/or staff made medical decisions for the resident. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Tolentino, in which this report was reviewed and a copy was provided.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

LIC9099 (FAS) - (06/04)

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