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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:25:08 PM


Document Has Been Signed on 09/19/2022 01:25 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AZZUR ASSISTED LIVING LLCFACILITY NUMBER:
331800003
ADMINISTRATOR:RADWAN BYRON GONZALOFACILITY TYPE:
740
ADDRESS:397 E MAIN STREETTELEPHONE:
(951) 665-6240
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:24CENSUS: 18DATE:
09/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Libvertdad AmalzonTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, and Licensing Program Manager (LPM) Joel Esquivel, arrived at the facility unannounced in order to cite deficiencies observed. LPA and LPM met with Administrator, Libertdad Almazon, who was informed of the purpose of the visit.

LPA observed in the medications room, that there was an unlocked door leading to the room, and a red bin with medication bottles and loose pills. LPA asked Administrator about the medication, and the administrator was unable to state if this medication was expired or refused medications. This poses an immediate health risk to residents in care.

LPA observed (3) resident rooms with oxygen tanks with no sign stating no smoking. LPA asked administrator how many residents where on hospice. Administrator was not able to state which residents were on hospice and why the resident rooms did not have a no smoking sign. This is a potential risk to residents in care.

LPA along with LPM observed a dead cockroach on the floor of the resident shower. This poses a potential risk for residents in care.

LPA observed a Hoyer lift in resident room #1. LPA asked administrator if the staff at the facility have proper training to use the lift. Administrator was unable to provide documentation for this training. This poses a potential risks to residents in care.

LPA reviewed roster for the facility and found that S1 was not associated to the facility. This is an immediate threat to the health and safety to residents in care. This will result in a civil penalty being issues fro S1 in the total of $500 dollars.

LPA also requested documentation for S1 and Administrator was unable to provide any documentation for this staff. This posses a potential risk to residents in care.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/19/2022
NARRATIVE
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These deficiencies were cited on an LIC809-D page along with plan of correction.

An exit interview was conducted where this report along with LIC809-D pages, and appeal rights were reviewed and provided to Administrator Liberty Almazon.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/19/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance...
This requirement was not met as evidence by:
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Administrator was unable to provide documentation for S1 being associated to the facility. LPA reviewed the roster and found that S1 was not listed on there.
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Type A
09/20/2022
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
This requirment was not met as evidenced by:
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LPA found medications that were unlockled in medical room. LPA found that the door to this room was unlocked.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/19/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirment was not met as evidenced by:
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LPA asked to see records for S1 and Adminsitrator was unable to provide these records. This poses a potential personal right, health or saftey risk to residents in care.
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Type B
09/29/2022
Section Cited

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(b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
This requirement was not met as evidenced by:
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LPA observed that (3) residents did not have a no smoking sign with and had oxygen tanks in their rooms. This poses a potential personal rights, halth, and saftey 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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/19/2022 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited

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(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirment was not met as evidenced by:
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Administrtor was able to provide proof of staff training for the Hoyer lift in bedroom #1. This poses a potential health, saftey, or personal rights risk.
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Type B
09/29/2022
Section Cited

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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...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirment was not met as evidenced by:
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LPA observed a dead cockorach on the floor of the resident restroom. This poses a potential personal rights, health or saftey 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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5