331800003-2-24-2021-18-AS-KCLS-BYQ2XF-20210301164705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 02/24/2021
Date Signed: 02/24/2021 05:00:10 PM

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
02/17/2021 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 18-AS-20210217161431

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: 21	DATE:	02/24/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Mary Jane Tolento		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident's engaging in a physical altercation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto contacted the facility via telephone to complete a complaint investigation via telephone due to COVID-19. LPA identified himself and discussed the purpose of the call and the elements of the allegations with the Administrator Mary Jane Tolentino. Tolento stated incident between resident #1 (R1) and resident #2 (R1) occurred at facility front entrance without warning as R1 claimed R2 had taken R1s hand bag. R1 and R2 were taken to hospital as precaution. Incident was documented and submitted to Licensing office.

Based on the information obtained there is not enough evidence that lack of supervision resulting in resident's engaging in a physical altercation . Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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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