331800003-6-10-2020-18-AS-NBRN-BQPPPY-20200618113015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 06/09/2020
Date Signed: 06/10/2020 08:11:22 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
06/20/2019 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20190620100127

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:	06/09/2020
		UNANNOUNCED	TIME BEGAN:	03:22 PM
MET WITH:	Mary Jane Tolentino, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident was illegally evicted
Facility charged resident for services not rendered
Facility failed to issue a refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, contacted Administrator, Mary Jane Tolentino, via telephone call to deliver the findings of the investigation on the above allegations.

Regarding the allegation, "Resident was illegally evicted," it was alleged Resident One (R1) was illegally evicted from the facility in June 2017 following a hospitalization. The LPA initiated the investigation into the allegation on June 28, 2019; records were reviewed and copies obtained. Interviews were conducted with staff and third party individuals. According to the Admission Agreement, R1 was admitted into the facility on 03/29/2017. Interviews conducted with staff could not identify the hospital R1 was admitted to nor the length of time of R1's admittance. According to Administrator Tolentino, R1 was evicted, though documentation of such an eviction was not observed on file. The Administrator also stated R1 was permitted to return to the facility following their discharge from the hospital. Records of dates of the eviction and the return of R1 were not on file. Staff interviewed could not identify whether R1 had returned to the facility or not, following the hospitalization. R1 could not be reached for an interview. This allegation is deemed UNSUBSTANTIATED at

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: 06/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

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-20190620100127

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: 06/09/2020

NARRATIVE

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this time.

Pertaining to the allegation, "Facility charged resident for services not rendered," it was alleged the facility received and cashed a check issued by a third party agency responsible for R1's placement. The check allegedly issued in February 2018 was in the amount of $1,423.69. The LPA initiated the investigation into the allegation on June 28, 2019; records were reviewed and copies obtained. According to a Resident Information sheet, services for R1 were discontinued on 07/17/2017. The Administrator stated she did not know if a check was issued to the facility by the agency and cashed on behalf of R1. The Administrator stated the third party agency did not pay rent for R1 for approximately two (2) months. Tolentino did not have dates for which the agency did not make payments for services provided. The Administrator stated the amount owed to the facility is approximately $2,000. R1 could not be reached for an interview. This allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Facility failed to issue a refund," it was alleged the facility failed to issue a refund to a third party agency responsible for R1's placement. The refunds included the remainder of one payment ($410.52) from June 2017, in which R1 was reportedly evicted, and of a second payment ($1,423.69) mistakenly issued by the third party agency after the resident was no longer in the facility. The LPA initiated the investigation into the allegation on June 28, 2019; records were reviewed and copies obtained. Per the Administrator, R1 returned to the facility following their hospital discharge in June 2017. Of the three (3) staff interviewed, two (2) denied having any knowledge on whether R1 was or was not evicted from the facility while one (1) reported R1 was not evicted. In addition, the Administrator could not recall if the facility received the February 2018 payment of $1,423.69. The Administrator reported the third party agency did owe the facility approximately $2,000 for services provided to R1 over the course of approximately two (2) months. The Administrator did not have dates of payments not made by the agency nor an exact dollar amount owed. Furthermore, R1 could not be reached for an interview. 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(s) occurred.

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

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

LIC9099 (FAS) - (06/04)

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