331800003-2-23-2022-18-AS-JESL-CLNT6B-20221130132654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:16:58 AM

Substantiated

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
02/15/2022 and conducted by Evaluator David Cuevas

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220215164951

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:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Edit Campos		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Physican order to stop medication and it was not followed by Facilty staff

INVESTIGATION FINDINGS:

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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 via telephone, as she was not present at the time of visit. Per Licensee caregiver, Edith can sign on her behalf.

During the investigation process, LPA conducted facility file review, conducted staff interviews and reviewed pertinent documents

Regarding allegation #1: Physician order to stop medication and it was not followed by Facility staff.

Based on the review of documents and interviews it was determined that Resident #1 (R1), was given doctors’ orders to discontinue a medication on 2/9/22. However, facility failed to communicate new orders to all staff members and R1’s medication was not stopped until 2/14/22, per medication administration records (MAR’s).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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-20220215164951

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: 02/23/2022

NARRATIVE

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As such allegation of, Physician order to stop medication and it was not followed by facility staff is being SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was done over the phone with Licensee, Mary Jane Tolentino were a copy of this report, LIC 9099 D, and appeal rights were reviewed and provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220215164951

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: 02/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/09/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need... 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 was not met, evidence by:	1 2 3 4 5 6 7	Licensee will train all staff members on medication dispensing and medication management, in addition to providing a statement of understanding as it relates to regulation being cited by POC date before deficiency can be cleared.
	8 9 10 11 12 13 14	Based on interviews and record review it was determine that R1 was to discontinue a medication on 2/9/22 but facility failed to communicate discontinued medication to all staff members. As a result, medication for R1 was not stopped until 2/14/22, this poses an immediate risk to the health, safety, and personal rights of resident s in care.	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: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

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