331800003-5-14-2025-18-AS-APEZ-DGPNUP-20250515104638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 05/14/2025
Date Signed: 05/14/2025 01:39:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/15/2022 and conducted by Evaluator Janette Romero

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20221115163004

FACILITY NAME:	AZZUR ASSISTED LIVING LLC		FACILITY NUMBER:	331800003
ADMINISTRATOR:	LIBERTY ALMAZAN		FACILITY TYPE:	740
ADDRESS:	397 E MAIN STREET		TELEPHONE:	(951) 665-6240
CITY:	SAN JACINTO	STATE: CA	ZIP CODE:	92583
CAPACITY:	0	CENSUS: 0	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:			TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility staff does not make residents aware of why they are on hospice and what services they are to receive.
Open wound not being treated as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) made several unsuccessful attempts to contact Licensee, Mary Jane Tolentino and Administrator, Liberty Almazan to deliver findings regarding the allegations listed above. Departmental records indicate the facility has been closed since 4/17/2023 and licensee and administrator have been unresponsive.

Regarding the allegation “Facility staff does not make residents aware of why they are on hospice and what services they are to receive” it was alleged several residents are unaware of the reason they are placed on hospice. No additional details were provided in the allegation. LPA conducted a record review and found on 4/19/2016, the facility was granted a hospice waiver for (6) residents. LPA reviewed a resident roster dated October 2022 which noted, “Prepared By: Mary Jane M Tolentino” on the top right corner. The roster listed 23 residents and included two (2) columns stating, “Hospice Yes or No” and “Hospice Provider Name”. Of the 23 residents listed in the roster, six (6) resident names stated “Yes” under the “Hospice Yes or No” column and 16 had a name or abbreviation under the “Hospice Provider Name”. Two (2) of two (2) staff were interviewed and reported the following information.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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-20221115163004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AZZUR ASSISTED LIVING LLC	FACILITY NUMBER: 331800003
	VISIT DATE: 05/14/2025

NARRATIVE

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Residents complained to them of not knowing the reason they were admitted to hospice. However, resident records were locked in the administrator’s office and inaccessible to care staff. Hospice records and information was not available for staff to review, and staff was only aware a resident was on hospice if management informed them, or they observe the resident receive hospice services at the facility. As a result, staff was unable to review residents’ hospice care plans to inform residents of the reason they were admitted to hospice and the types of services they should expect to receive. Both staff were not aware if Licensee, Mary Jane Toletino or Administrator, Liberty Almazan informed residents the reason they were placed on hospice or what services they should expect to receive. The facility failed to provide the Department with resident and hospice records. As a result, LPA was unable to review hospice records or locate residents’ whereabouts/contact information for an interview. One (1) additional staff declined to be interviewed, and LPA made several unsuccessful attempts to make contact with Licensee Tolentino and Administrator Almazan.

Regarding the allegation, “Open wound not being treated as required” it was alleged Resident 1 (R1) had an open wound, was admitted to a different hospice provider, and did not receive wound care. R1 is listed as a resident in the October 2022 resident roster. However, the facility failed to provide the Department with a copy of R1’s resident records. As a result, LPA was unable to locate R1’s whereabouts or contact information for an interview. Two (2) staff were interviewed and reported the following information. R1 had a wound on their foot that was being treated by hospice. Facility caregivers provided R1 with as needed wound care after receiving wound care training from hospice. One (1) of two (2) staff interviewed reported noticing that at some point, R1 stopped receiving services/wound care from hospice but since hospice records were unavailable for review, staff was not aware when a resident was discharged from hospice. Both staff were unable to report whether R1’s wound was open and required further treatment when the Department received the complaint. One (1) additional staff declined to be interviewed, and LPA made several unsuccessful attempts to make contact with Licensee Tolentino and Administrator Almazan for an interview. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. Due to the facility's closure and the licensee and administrator being unresponsive, LPA was unable to conduct an exit interview and a copy of this report and Confidential Names list (LIC 811) will be mailed to the facility’s mailing address on file.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC9099 (FAS) - (06/04)

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