331800003-10-28-2021-18-AS-JESL-CA925E-20211231160526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 10/27/2021
Date Signed: 10/28/2021 10:56:51 AM

Substantiated

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
10/25/2021 and conducted by Evaluator David Cuevas

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211025130029

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: 5	DATE:	10/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee, Mary Jane Tolentino		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
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5
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8
9

Illegal Eviction.

INVESTIGATION FINDINGS:

1
2
3
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5
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9
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13

Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility to initiate an investigation for the above allegation. LPA met with Licensee, who was informed of purpose of visit.

Regarding allegation of illegal eviction, per interview and record review it was identified that resident # 1(R1) was taken to hospital on 10/18/21 due to a COVID outbreak at the facility. Per reported allegation, facility refused to take back resident # 1 after being discharged. Licensee confirmed an eviction notice had not been issue for R1. Additionally facility refused to take resident back until R1 is COVID cleared. As such allegation of illegal eviction is SUBSTANTIATED. Def will be cited.

An exit interview was done with Licensee and a copy of this report, LIC9099D, and appeal right provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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-20211025130029

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/10/2021 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction Procedures:87224(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met evidence by.	1 2 3 4 5 6 7	Licensee will review and provide a statement of Aknowledgement stating that facility understands regulation and will abide by sections 87224(a) by November 10, 2021.
	8 9 10 11 12 13 14	Licensee refused to accept R1 back to facility upon hospital discharge. This pose a potential health and safety risk to resident.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David Cuevas	TELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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