331800003-5-14-2025-18-AS-JDHS-DGWTDK-20250522143821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 05/14/2025
Date Signed: 05/14/2025 02:37:58 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
12/14/2022 and conducted by Evaluator Janette Romero

COMPLAINT CONTROL NUMBER: 18-AS-20221214135139

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:	11:10 AM
MET WITH:			TIME COMPLETED:	11:11 AM

ALLEGATION(S):

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Staff hit resident
Multiple residents sustaining wounds while in care due to staff neglect
Staff do not ensure that residents are adequately hydrated
Staff do not screen visitors
Facility exceeded hospice waiver

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. At this time, licensee and administrator have been unresponsive.

Regarding the allegation, “Staff hit resident” it was alleged Resident 1 (R1) was hit by Staff 1 (S1). It was further alleged Administrator Almazan attempted to hit R1 but missed. LPA reviewed a resident roster dated November 13, 2022, which noted, “Prepared By: Mary Jane M Tolentino” on the top right corner and includes R1 as a facility resident. LPA also reviewed a Personnel Report (LIC 500) dated November 15, 2022, which includes S1 and Administrator Almazan as facility employees. The facility has yet 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. LPA conducted a collateral visit and interviewed S1 who reported the following information. R1 disliked residing in the facility and on one (1) occasion R1 attempted to hit S1. During the incident, S1 feared for their life and became motionless due to being in complete shock.

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: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 18-AS-20221214135139

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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S1 added Staff 2 (S2) intervened and directed R1 to not hit S1, to which R1 complied without further incident. During a different occasion, S1 heard Administrator Almazan verbally disagreeing with R1 but S1 never observed Administrator Almazan hit R1 or any other resident in the facility. S2 was interviewed and corroborated witnessing R1 attempt to hit S1 and intervening to stop the incident. Both staff reported they have never physically assaulted R1 or any other resident in the facility and listed R1 as the verbal aggressor. S2 added they have never observed or have knowledge Administrator Almazan physically assaulted any of the residents in the home.

Regarding the allegation, “Multiple residents sustaining wounds while in care due to staff neglect” it was alleged several residents have wounds being cared for by outside agencies only and not facility staff. No additional details were provided in the allegation. Since the facility has not provided a copy of resident records, LPA was unable to review records to determine which residents received wound care from outside agencies. As a result, LPA was also unable to obtain the alleged victims’ contact information for an interview. Two (2) staff were interviewed and reported the following information. 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 or home health if management informed them, or if they observed the resident receive hospice/home health services at the facility. Some residents had wounds that were being treated by hospice. Caregivers received wound care training from hospice and provided as needed wound care to the residents who required it.

Regarding the allegation, “Staff do not screen visitors” it was alleged several people go in the facility without being screened or signing in. Only one (1) of two (2) staff interviewed corroborated the allegation. One (1) of two (2) staff interviewed reported that prior to the facility’s closure, staff began screening visitors and asking them to sign a visitor’s log. One (1) of two (2) staff interviewed was unable to provide an estimated date or year the facility began screening visitors. Due to the facility’s not providing pertinent records, LPA was unable to review the visitor’s log to confirm this information.

Regarding the allegation, “Staff do not ensure that residents are adequately hydrated” it was alleged residents are only served water. Two (2) staff interviewed reported the facility always had water available for the residents to drink and occasionally provided them juice, iced tea, milk, or sodas with meals. The facility has yet to provide written information as proof of water/drink options purchased for the residents to refute the allegations.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20221214135139

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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It was alleged the “Facility exceeded hospice waiver”. 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”. LPA also reviewed a resident roster dated November 23, 2022, which also noted, “Prepared By: Mary Jane M Tolentino” on the top right corner and listed the same resident names as the October 2022 roster. Of the 23 residents listed in the November 23, 2022 roster, six (6) resident names stated “Yes” under the “Hospice Yes or No” column and only six (6) had a name under the “Hospice Provider Name”. Two (2) staff were interviewed and reported not being aware of the maximum number of terminally ill residents the facility was allowed by the Department to accept/retain at a time. Two (2) staff interviewed reported observing more than six (6) facility residents received hospice services at facility at the same time. One (1) of two (2) staff interviewed reported the majority of the residents residing in the facility received hospice services during the same timeframe, which would have exceeded the approved hospice waiver to accept/retain only six (6) residents at a time. The facility has yet to provide residents’ hospice records for Departmental review.

Due to resident records being unavailable for review, LPA was unable to locate residents’ last known whereabouts or 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 allegations. Although the allegations may have happened or are 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: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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