331800003-8-11-2020-18-AS-KCLS-BSFU4Z-20200813151558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 08/11/2020
Date Signed: 08/11/2020 05:09:26 PM

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
06/02/2020 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200602095459

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:	08/11/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Mary Jane Tolento		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not administering medication according to physician's order.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto contacted the facility administrator Mary Jane Tolento, via telephone and email, due to COVID-19 social distancing, to conclude a complaint investigation. LPA Prieto identified himself and discussed the purpose of the call and the elements of the allegations that staff are not administering medication according to Physician's orders. LPA Prieto interviewed hospice staff who states that medication is given to resident #1 (R1), but could not receive a satisfactory explanation from facility staff as to R1's drug administration record. Facility staff produced R1's physician's order and drug administration records and appear to be in order. LPA interviewed R1, in question, who states that medications are given on a daily basis and when asked, medication are given when requested (PRN).

Based on the information obtained there is not enough evidence that staff are not administering medication according to physician's order. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020

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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