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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:16:43 PM


Document Has Been Signed on 03/27/2023 12:16 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: 19DATE:
03/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Adminsitrator, Liberty AlmazanTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a plan of correction visit. The LPA met with administrator, Liberty Almazan who was informed of the purpose of the visit.

During the visit a health and safety check was conducted on the facility residents. During the time of the visit LPA conducted a walk through of the facility interior and exterior. LPA observed the residents, the food supply, and utilities.

The following deficiency was corrected during today's POC visit:
Deficiency cited under Title 22 Regulation 87506(a) Resident Records. POC to have the (2) missing files from 3/22/2023 for Resident #1 (R1) and Resident #2 (R2) sent to the LPA by the POC due date of 3/29/2023. Deficiency has been cleared as during this visit as the administrator provided the LPA will both resident files. Clearance letter was given to administrator during the time of the visit.

The following deficiencies were not corrected by the POC due date nor at the time of the visit. Civil Penalties are being assessed and will continue to accrue until correction has been submitted:
Deficiency cited under Title 22 Regulation 87307(d)(3) Maintenance and Operation. The POC made with the licensee was 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 construction to ensure the health and safety of the residents. On today's visit .LPA observed additional caution tape that was placed around the trench but no barrier to ensure the health and safety of the residents. Civil penalties are being assessed for the dates of 3/24/2023 to 3/27/2023 in the amount of $100 per day for 4 days. Civil penalties will continue to accrue at the rate of $100 until a barrier is placed.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 03/27/2023
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Deficiency cited under Title 22 Regulation 87303(a)(1) Maintenance and Operation. The LPA contacted the licensee who refused to make definitive plan of correction for the issue on the visit on 3/22/2023. On today's visit the LPA observed and took photos of the roof that is in need of repair, and conducted an interview with administrator who stated that this room is still accessible to facility staff. The administrator stated that they will have the food supply moved and make the room inaccessible to clients and staff meanwhile repairs are made. A civil penalty is being assessed for the repeated violation in the amount of $250. Civil penalties will continue to be assessed until the corrections are made and submitted to the LPA.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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