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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 09/19/2022
Date Signed: 09/19/2022 01:33:59 PM

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
10/27/2021 and conducted by Evaluator Janira Arreola
COMPLAINT CONTROL NUMBER: 18-AS-20211027103318
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
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Libertad AlmazonTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Resident fell resulting in bruising.
Unlawful eviction.
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for the purpose of a follow-up on a complaint investigation. LPA arrived to the facility at 9/19/2022 at 9:20 a.m. with Licensing Program Manager (LPM) Joel Esquivel, and met with Administrator, Libertad Almazon.

LPA took a tour of the facility, conducted interviews and documented records review. Regarding allegation #1 "Resident fell resulting in brusing" LPA reviewed the resident roster and found that Resident 1 (R1) is no longer residing at the facility. Administrator stated that the resident did sustain a fall at the facility but was unable to provide documentation for needed treatment to the resident. Therefore the allegation is substantiated due to the facility lacking records for the incident.

Regarding allegation #2 "Unlawful eviciton", LPA requested documentation of a 30-day eviction for R1 there was no documentation provided at the time of the visit. Based on Administrator interview, the administrator was unable to state whether the R1 had been served an eviciton notice. Therefore, the allegation is substantiated.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
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
10/27/2021 and conducted by Evaluator Janira Arreola
COMPLAINT CONTROL NUMBER: 18-AS-20211027103318

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
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator, Libertad AlmazonTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident went AWOL from facility.
Failed to report - Resident had COVID.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for the purpose of a follow-up on a complaint investigation. LPA arrived to the facility at 9/19/2022 at 9:20 a.m. with Licensing Program Manager (LPM) Joel Esquivel, and met with Administrator, Libertad Almazon.

Regarding Allegation #1 " Resident went AWOL from the facility". LPA requested documentation of resident AWOL from facility. Administrator was unable to find documentation for the AWOL. Resident involved is no longer residening at the facility. Based on the fact that LPA was unable to corrobatate the allegation claims, the alleagtion is unsubstantiated.

Regarding allegation #2 "Failed to report- Resident had COVID". LPA requested documentation or proof of resident having tested positive for COVID-19 and the facility reporting it to the department. The administrator was unable to provide documentation for this incident. The facility is under new administratoration with the administrator stating the past administrator would have been the one to report the COVID-19 case. Based on the fact that the past administrator is no longer present, resident is no longer present, and there is no documentation for the incident this allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20211027103318
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: 09/19/2022
NARRATIVE
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A finding of unsubstantiated means that although the alleagtion is valid, the prodonderance of the evidence standard has not been met.

An exit interview was conducted where this report was reviewed and provided to Administrator, Libertad 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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20211027103318
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: 09/19/2022
NARRATIVE
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A finding of substantiated means that the prodonderance of the evidence standard has been met for allegations above.

An exit interview was conducted with Administrator, Libertad Almazon, where this report was review, as well as LIC809-D pages and appeal rights.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20211027103318
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: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
87724(a)
1
2
3
4
5
6
7
"87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required..." This requirement was not met as evidenced by:
1
2
3
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5
6
7
Administrator will read the section cited here and submit a written signed statment stating they have read and understood the regulation by the POC date.
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9
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14
LPA found a lack of records at the facility for R1 eviciton notice, and Administrator stating they were not certain of the resident being served an eviciton notice. This poses a potential health, saftey or personal rights risk.
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9
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1
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1
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7
1
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7
1
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20211027103318
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: 09/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2022
Section Cited
CCR
87465(a)(7)
1
2
3
4
5
6
7
87465 Incidental Medical a and Dental (a) A plan for incidental medical and dental care shall be developed by each facility...(7) There shall be adequate privacy for first aid treatment of minor injuries and for examination by a physician if required." This requirment was not met as evidenced by:
1
2
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Administrator will read the regualtion cited here and will write a letter stating that they have read and understood the regulation. Administrator will sign and submit this to LPA by POC date.
8
9
10
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12
13
14
Administrator admitted to the resident fall but was unable to provide proof of proper care for the resident's injuries.
8
9
10
11
12
13
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1
2
3
4
5
6
7
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2
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5
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7
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7
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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
LIC9099 (FAS) - (06/04)
Page: 6 of 6