<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 09/29/2021
Date Signed: 09/29/2021 05:03:32 PM

Unsubstantiated


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
09/23/2021 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20210923122415
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: 19DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Mary Jane TolentinoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member verbally abuses residents in care.
Resident sustained bruising while in care.
Residents' hygiene needs are not being met.
Staff is not maintaining proper logging of events at the facility.
Facility food is not adequate for residents in care.
Facility has pests.
Facility is odoriferous (smells of urine and poop).
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility above to initiate an investigation for 10-day complaint. LPA identified self and informed Licensee, Mary Jane Tolentino of the purpose of visit.

During the investigation process, LPA conducted facility file review, interviewed: staff, and residents, and reviewed pertinent documents

Regarding allegation #1: Staff member verbally abuses residents in care.

Based on collected interviews from residents in care no information was provided that would Identify resident in care a being verbally abused by staff at the facility. Additionally, resident interviewed reported to feel safe and treated with dignity and respect at the facility. As such the allegation of staff member verbally abuses residents in care is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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 8
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
09/23/2021 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20210923122415

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: 19DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Mary Jane TolentinoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not maintained clean and sanitized.
Residents' laundry needs are not being met.
Staff smoke at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility above to initiate an investigation for 10-day complaint. LPA identified self and informed Licensee, Mary Jane Tolentino of the purpose of visit.

Regarding allegation #1: Facility is not maintained clean and sanitized.

Based on observation done while conducting facility walkthrough LPA was able to observe a need for cleaning in restrooms and hallway floors located in buildings 377 E and in 397 E. Floor were sticky and stain can be observed in floor and doorways. As such based on the observation made the allegation of Facility is not maintained clean and sanitized is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 18-AS-20210923122415
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: 09/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation # 2: Residents' laundry needs are not being met.

Based on observations done while conducting facility walkthrough and interviews with staff, LPA identify facility to have broken down laundry equipment and to only have 1 working dryer to fulfil all laundry needs. Additionally, LPA observed facility to be hanging clothes in clothing line outside to be dried by the sun. As such allegation of Residents' laundry needs are not being met is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met

Regarding Allegation # 3: Staff smoke at the facility.

Based on observations, during facility walkthrough LPA observed staff # 2 to be smoking within at the facility just outside laundry station while performing staff duties. LPA observed ground around that area to have discarded cigarette butts on the floor. As such allegation staff smoke at the facility is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met

An exit interview was conducted with Licensee, were a copy of this report LIC 9099, LIC 9099 D, and appeal rights were provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 18-AS-20210923122415
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
80087(a) Buidling and grounds; (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This posed an immidiate healthand safety risk to resident in care.
1
2
3
4
5
6
7
LIcensee, will create and submit a cleaning shedule for commonly touches surfaces and bathrooms and send over to LPA by due date before deficiencie can be cleared.
8
9
10
11
12
13
14
This requirement is not been met evidence by, observations made in buildings 377 E and in 397 E. Floor were sticky and stain can be observed in floor and doorways.
8
9
10
11
12
13
14
Type B
10/13/2021
Section Cited
CCR
87303(g)(1)
1
2
3
4
5
6
7
87303(g)(1): Maintanance and Operations,(g) Facilities which have machines and do their own laundry shall:(1) Have adequate supplies available and equipment maintained in good repair.This posed an immidiate healthand safety risk to resident in care.
1
2
3
4
5
6
7
Licensee will repair or replace existing landry equiptment by due date before deficiencie can be cleared.
8
9
10
11
12
13
14
This requirement was not met evidence by, laundry equiptment at the facility is currently not working.
8
9
10
11
12
13
14
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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20210923122415
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
80075
1
2
3
4
5
6
7
80075 Health Related Services; (2) Ensuring that the following conditions are met if oxygen equipment is in use:(C) Smoking is prohibited where oxygen is in use.This posed an immidiate healthand safety risk to resident in care.
1
2
3
4
5
6
7
Licensee will develop a memo infroming staff to not to smoke at the facility unless it is in a designated area or out of facility grounds by due date before deficiency can be cleared.
8
9
10
11
12
13
14
This requirement is not met evidence by LPA observing S2 smoking right outside laundry area.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 18-AS-20210923122415
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: 09/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding allegation # 2: Resident sustained bruising while in care.

Based on interviews, observations, and documents reviewed. Resident who are bedbound are receiving services from a licensed professional who comes out to facility to provided needed services. As such the allegation of Resident sustained bruising while in care is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation # 3: Residents' hygiene needs are not being met.

Based on collected interviews from residents in care and LPA’s observation it appears that residents are provided with the needed hygienic supplies needed. Additionally, LPA observed resident in placement to well-groomed and hygiene products to be available at the facility. As such the allegation of residents' hygiene needs are not being met is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding Allegation # 4: Staff is not maintaining proper logging of events at the facility.

Based on facility file review and LPA’s observation facility seems to be properly logging needed information both in residents file and facility file. Additionally, LPA observed facility to be conducting daily temperature checks for residents. As such the allegation of staff is not maintaining proper logging of events at the facility is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 18-AS-20210923122415
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: 09/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation # 5: Facility food is not adequate for residents in care.

Based on residents’ interviews and LPA’s observation facility seems to have an adequate amount of food available for residents and to have alternative to meals for residents with special diets. Additionally, LPA observed a daily menu with different food options throughout the week. As such the allegation of staff is not maintaining proper logging of events at the facility is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding Allegation # 6: Facility has pests.

LPA conducted a walkthrough throughout the 3 buildings conducting random checks in bedroom for bed bugs and other pest and did not identify any pest present at the time of inspection. Staff did report facility to have had a bed bug situation in the past but since then treatment has been done and further concerns have been communicated. As such the allegation of facility has pest is deemed UNSUBSTANTIATED at this time; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding Allegation # 7: Facility is odoriferous (smells of urine and poop).

LPA conducted a walkthrough throughout the 3 buildings conducting random checks in bedroom and bathrooms and identify facility to be free of smells of urine and poop. Additionally, staff interviews reported facility to be cleaned throughout the day during their shift. ; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 18-AS-20210923122415
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: 09/29/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
An exit interview was conducted with Licensee were this report was reviewed and provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8