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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:24:23 PM


Document Has Been Signed on 03/22/2023 03:24 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:LIBERTY ALMAZANFACILITY TYPE:
740
ADDRESS:397 E MAIN STREETTELEPHONE:
(951) 665-6240
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:24CENSUS: 20DATE:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff, Juana GonzalezTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Anaylsts (LPAs) Janira Arreola and Janette Romero conducted an unannounced visit to the facility to in order to conduct a case management visit. The LPAs met with staff, Juana Gonzalez who was informed of the purpose of the visit.

LPAs were informed that the administrator was not on the premise and was at an appointment and would not be able to meet the LPAs, and that the licensee was not able to meet the LPAs at the facility in a timely manner. LPAs spoke with administrator and the licensee over the phone during the visit.

LPAs were informed by the Licensee that the building owner had issued the licensee a 30-day notice to vacate the premises. LPAs came to the facility in order to obtain resident information. LPAs spoke with the licensee on relocating the residents and informed the licensee that 60-day notices would have to be served to the residents.

LPAs conducted records review, conducted interviews with staff and residents, and documented observations. LPAs also conducted a tour of the interior and exterior of the facility.

LPAs observed the following deficiencies:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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 4


Document Has Been Signed on 03/22/2023 03:24 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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2023
Section Cited

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(a) The facility shall be clean, safe, sanitary and in good repair at all times...
(1) Floor surfaces in bath...kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirment was not met as evidenced by:
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The LPA contacted the licensee who refused to make definitive plan of correction for the issue. The LPA suggested moving the food supply and making the room inaccesible, which the licensee refused to do.
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The LPAs found leaks in the staff lounge where facility food is being stored. This poses an immediate health, saftey or personal rights risk for residents in care.
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Type A
03/23/2023
Section Cited

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(d) The following space and safety provisions shall apply to all facilities:
(1) Sufficient room shall be available to
(3) All persons shall be protected against hazards within the facility... Thus requirment was not met as evidenced by:
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The licensee agreed to put a barrier in place to prevent residents from entering the area. The licensee also agree to send the LPA a written plan by the POC due date on how the licensee plans to deal with the contruction to ensure the healh and saftey of the residents.
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The LPAs observed an open trench in the facility backyard as well as maintence personnel actively digging in the trench. LPAs observed no saftey precautions in place to safeguard the residents from the trench. This poses an immediate health, saftey, or personal rights 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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 03/22/2023
NARRATIVE
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  • LPAs observed there was a trench that was 1 foot wide and 3 feet deep in the facility yard. LPAs spoke with the license who stated that the trench had been there for (1) month. LPAs spoke with the resident who also reported the trench in the yard for (1) month. Residents also reported that when they go into the yard at night, there is no lighting in that area where the trench is. The LPAs observed a handy man actively digging in the trench when the LPAs where at the facility. LPAs spoke with the handy man who stated that they were trying to fix a broken pipe. LPAs were informed by staff that this was due to a plumbing issue. LPAs conducted a walk thorough and observed all resident restrooms where flushing and had running water. LPAs observed no saftey measures were in place to safeguard the residents from this area. The facility is being issued a type A deficiency for this and documented a plan of correction.
  • LPAs observed in the staff lounge area where the facilities commercial freezer is kept with facility celing had several leaks in the ceiling. LPAs took photos of this and found absorbent liner pads covering the floor and the table where staff sit in the lounge. Licensee informed the LPAs that new construction would need to be done and a permit would need to be obtain to fix the issue. LPAs were informed that this a room for staff only. LPA spoke with licensee and requested the licensee to make a plan of correction for this issue, but the licensee refused to provide a definitive plan and date to when this issue would be fixed, or an alternate location on where to place the commercial freezer or to make to room inaccessible until repairs were made. A type A deficiency was documented for this.
  • LPA requested records for all residents and found that staff was unable to provide (2) resident files out of the (2) resident. The facility will receive a type B deficiency for this and plan of correction was documented for this.

The licensee was advised over the phone that an office meeting would need to take place and that the department would be in contact with them to establish a date and time.

An exit interview was conducted where this report along with :LIC 809-D pages and appeal rights were reviewed and provided to staff, Juana Gonzalez.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/22/2023 03:24 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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2023
Section Cited

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirment was not met as evidenced by:
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The licensee will fax the (2) missing fileas to the LPA by the POC dyue date.
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The LPAs were not provided with (2) staff files by the facility staff. The staff was unable to locate them. This poses a potenital personal, health or saftey risk to the residents in care.
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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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4