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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 07/27/2021
Date Signed: 07/27/2021 05:39:40 PM

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:RADWAN BYRON GONZALOFACILITY TYPE:
740
ADDRESS:397 E MAIN STREETTELEPHONE:
(951) 665-6240
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:24CENSUS: 20DATE:
07/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mary Jane Tolentino, LicenseeTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations of Title 22, Division 6, Chapter 8, observed during the investigation of complaints: #18-AS-20191219111821 and #18-AS-20210510172726.

During a records review for each complaint the LPA observed violations related to Resident One's (R1's) and Two's (R2's) Physician's Report for Residential Care Facilities for the Elderly (RCFE).

R1's report, which documents the resident's medical assessment, shows the assessment was conducted on July 10, 2017. This report indicates R1 is diagnosed with Dementia. A subsequent assessment should have been conducted in the following years the resident remained in the facility. No updated medical assessments were observed on file. Licensee Tolentino could not recall if updated assessments were conducted. A citation will be issued.

R2's report was observed to be missing a physician's signature. Licensee Tolentino could not recall if R2 received an assessment or not. A citation will be issued.

An exit interview was conducted with Tolentino; this report was reviewed, and a copy provided, along with LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited

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CARE OF PERSONS WITH DEMENTIA: Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: Each resident...shall have an annual medical assessment...This requirement was not met as evidenced by: Based on records review the Licensee did not ensure an annual
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medical assessment was conducted for R1. No updated medical assessments were observed on file for R1. Licensee Tolentino could not recall if updated assessments were conducted.
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Type B
08/03/2021
Section Cited

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MEDICAL ASSESSMENT: Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...This requirement was not met as evidenced by: Based on records review, the Licensee did not ensure a
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medical assessment was conducted for R2. R2's report was observed to be missing a physician's signature. Licensee Tolentino could not recall if R2 received an assessment or not.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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