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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 04/12/2023
Date Signed: 04/12/2023 04:32:59 PM


Document Has Been Signed on 04/12/2023 04:32 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: 8DATE:
04/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Staff, Susan DunnTIME COMPLETED:
04:45 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. When LPA arrived Administrator stated they were on their way out as they had a medical emergency. LPA observed the administrator had red marks on the left side of her face and on her feet. LPA conducted the visit with staff, Susan Dunn.

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 Health and Safety Code 1569.682(b) Transfer of resident upon forfeiture of license or change in use of facility. During office meeting on 3/28/2023 the department staff was informed that the licensee had not submitted a closure plan to the department after receiving notice from the property owner, on their intent to sell the property. POC was to send a written closure plan by 3/31/2023 to the LPA. The LPA received this written plan via email by the POC due date. During the visit, the LPA left a clearance letter for this.

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 roof in the staff lounge area is no longer leaking. LPA also observed the facility freezer has been moved to the facility kitchen. LPA also received a photo of proof of correction from the licensee on 4/3/2023 showing the freezer had been moved to the facility kitchen. The deficiency is being cleared, and civil penalties are being assessed for the period leading up to the correction. This is from 3/31/2023 to 4/3/2023, in the amount of $100 for 4 days. Clearance letter was present to staff during the visit.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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: 04/12/2023
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Deficiency cited under Title 22 Regulation 87211(a)(1)(A) Reporting Requirements. 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. POC was to submit the death report to the regional office by 3/31/2023. The regional office received death report for R1 on 4/3/2023. Civil penalties are being assessed for the period leading up to the correction. This is from 4/1/2023 to 4/3/2023 in the amount of $100 per day for 3 days. Clearance letter was present to staff at the time of the visit.

Deficiency cited under Title 22 Regulation 87224(a)(5)(A)(1) Eviction Procedures. During office meeting on 3/28/2023 it was found that the licensee had not served the facility residents a 60-day eviction notice for change of use of the property. POC was to submit eviction notice to LPA by 3/31/2023. The LPA received the eviction notice on 4/2/2023. Civil penalties are being assessed for the period leading up to the correction. This is from 4/1/2023 to 4/2/2023 in the amount of $100 per day for 2 days. Clearance letter was present to staff at the time of the visit.

An exit interview was conducted with the licensee, Mary Jane Tolentino over the phone, and with staff, Susan Dunnin person. This report along with LIC421FC pages were reviewed and provided to, Susan Dunn.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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