331800003-4-10-2023-18-AS-JESL-CR4TKX-20230421144840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 04/10/2023
Date Signed: 04/10/2023 06:18:33 PM

Unsubstantiated

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
12/28/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211228095028

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: 11	DATE:	04/10/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Licensee Mary Jane Tolentino, Caregiver Juana Gonzalez		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility transferred residents without proper authorization.
Facility staff abandoned residents at hospital.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegations(s) listed above. LPA met with Licensee Mary Jane Tolentino via telephone and Caregiver Juana Gonzalez and explained the purpose of the visit and elements of the allegations. The investigation consisted of observation, interviews, and record review.

Regarding the allegation facility transferred residents without proper authorization
In October 2021 there was a total of fifteen (15) residents that tested positive for Covid-19. Per Licensee Mary Jane she called a provider to help provide guidance on how to best deal with the situation. At the time staffing was limited as staff were contracting the virus themselves. Feedback provided from conducted interviews revealed that Mary Jane had then contacted the mobile medical health provider that was contracted to conduct weekly covid-19 testing for the facility. Mary Jane was seeking guidance on how to best handle having fifteen, Covid-19 positive resident’s that were exhibiting severe symptoms and were in need of medical attention.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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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Control Number 18-AS-20211228095028

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: 04/10/2023

NARRATIVE

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Mary Jane also stated that the staff are not trained to take care of COVID patients and that they are exhausted. Administrator Mary Jane was informed that the facility would be referred to Foothill Regional Hospital to see if they would be able to accommodate the covid positive residents. Additional feedback provided was that Mary Jane was informed that the hospital was located in Tustin, CA. Further, Mary Jane agreed the priority is to have the residents receive proper care. All fifteen (15), Covid-19 positive residents including resident #2 (R2), were transferred to a total five (5) different hospitals throughout Orange County. The hospitals had beds that could accommodate the residents and give the proper medical care that was needed. With the local hospitals not having any beds available, the best option was to have the residents get the care that they needed. Interviews conducted revealed that Mary Jane did contact the residents responsible party to inform them that the resident was positive. Per the facility’s mitigation plan, they are to request assistance when needed, and by Mary Jane stated that, that is why she contacted the mobile health provider. R1 was Covid positive and needed to be sent out, but would return to the facility once they are no longer producing a positive covid test result. Based on observation, interview and record review the allegation facility transferred residents without proper authorization is UNSUBSTANTIATED.

Allegation: Facility staff abandoned residents at hospital

Resident #2 (R2) was transferred to a hospital in Orange County due to being positive for Covid-19 there were not any beds available at the local hospitals. Per interviews conducted with hospital staff the purpose of the resident being admitted was in fact just for quarantine. Additional feedback provided was that R2 was going to be transferred to a skill nursing facility as they were in need of having hemodialysis,a trach and other rehabilitation needs. Mary Jane stated that she does not have control over what the doctor ordered for R1 and why they were sent to a skilled nursing facility in Marina Del Rey. There was not enough evidence to support the allegation, therefore the allegation facility staff abandoned residents at hospital is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided to Caregiver to Juana Gonzalez.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
12/28/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211228095028

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: 11	DATE:	04/10/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Licensee Mary Jane Tolentino, Caregive Juana Gonazlez		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff did not notify responsible party of resident's change in medical condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegations(s) listed above. LPA met with Licensee Mary Jane Tolentino via telephone and Caregiver Juana Gonzalez and explained the purpose of the visit and elements of the allegations. The investigation consisted of observation, interviews, and record review.

Documentation reviewed revealed that Administrator Mary Jane did in fact send written communication to Resident #2 (R2) responsible party on October 30, 2021, informing them that R2 was positive for Covid-19 and needed to be sent out for further medical evaluation. There was no response given, but a "read recipient" was observed. Mary Jane stated that she did follow up with a phone call and did not receive a response. Based on observation, interview and record review the allegation facility staff did not notify responsible party of resident's change in medical condition is UNFOUNDED. A finding that the complaint is UNFOUNDED means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint. An exit interview was conducted and a copy of this report was provided to Caregiver to Juana Gonzalez.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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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