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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:52:09 PM


Document Has Been Signed on 03/30/2023 03:52 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:
03/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensee, Mary Jane TolentinoTIME COMPLETED:
04:00 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 licensee Mary Jane Tolentino 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.

The following deficiency was corrected during today's POC visit:
Deficiency cited under Title 22 Regulation 87307(d)(3) Physical Environments and Accommodations. POC was to put a barrier in place to prevent residents from entering the area where a trench was being dug in the facility yard. The licensee also agreed 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. During today's visit LPA observed that a chain link fence has been installed around the entire permitter of the trench. Written plan was given to the LPA at the time of the visit. 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 87303(a)(1) Maintenance and Operation. On 3/27/2023 LPA made plan of correction with facility administrator to have food supply moved from staff lounge area where the roof is leaking and make the room inaccessible to clients and staff meanwhile repairs are made. During today's visit, LPA observed the food supply in still present in the staff lounge area, and observed staff taking their break in this room. A civil penalty is being assessed for the repeated violation from 3/28/2023 to 3/30/2023 in the amount of $100 per day for 3 days. 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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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: 03/30/2023
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During office meeting conducted on 3/28/2023 with the licensee, department staff was informed that the licensee had been notified of the home owner's intent to list and sell the property. The licensee stated they were informed of an interested buyer in October of 2022. Department staff was informed that the licensee did not submit a closure plan to the department and did not issue a 60-day notice of change of use of the property to the facility residents. The licensee will be cited a Type A deficiency for failure to submit a closure plan to the department. The licensee will also be cited another Type A deficiency for failure to issue a 60 day notice. Plans of corrections were documented with the licensee.

During today's visit LPA requested copies of all documents in all resident files. LPA took (16) resident files on today's date. LPA gave the licensee a list of files taken. The licensee stated they or the administrator would go to the Riverside regional office and pick up the files on 4/3/2023. It was found that Resident #1 (R1) had passed away on 3/17/2023 and death report had not been sent to the licensing office. The facility will receive a Type A deficiency for this. Plan of correction was documented with the licensee.

An exit interview was conducted where a copy of this report along with appeal rights and LIC809-D pages were reviewed and provided to licensee, Mary Jane Tolentino.Database Link Icon
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/30/2023 03:52 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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited

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(b) If seven or more residents...will be transferred as a result of...forfeiture of a license or change in the use of the facility...the licensee shall submit a proposed closure plan to the department for approval. The department...This requirment was not met as evidenced by:
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The licensee agreed to send the LPA a written closure plan by the POC due date.
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Based on interview with the licensee, it was found that the licensee did not send the department a closure plan. Thsi poses an immediate health, saftey or personal rights risk to residents in care.
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Type A
03/31/2023
Section Cited

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(a) The licensee may evict a resident for...(5) Change of use of the facility.(A)The licensee...upon no less than sixty (60) days written notice, evict a resident...1...written notice to evict..shall include all requirements specified in Section 1569.682(a)(2)(A) through (F)...
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The licensee agreed to draft an evcition notice to all residents and sent the department a copy of the notice. The notice shall include all required elements under the section sited. Thsi is due by the POC due date.
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This requirment was not met as evidenced by: Based on interview with licensee and property owner, it was foudn that the licensee did not give the facility residents a 60-day eviction notice for change of use of the facility.
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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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/30/2023 03:52 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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2023
Section Cited

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(a) Each licensee shall furnish...(1) A written report...to the licensing agency...within seven days of the occurrence of any of...(A)Death of any resident from any cause regardless of where the death occurred... This requirment was not met as evidenced by:
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The licensee agreed to send the LPA the death report for R1 by the POC due date.
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Based on records review and interviews, it was found that a death report was not sent for R1 to the licensing office. Thsi p[oses an immediate health, saftey or personal rights risk to 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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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