331800003-6-9-2021-18-AS-NBRN-C6ETUS-20210831150248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:20:21 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
05/10/2021 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210510172726

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:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ma Satchel Lecita, Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation on the above allegation. The LPA was greeted met with Administrator, Ma Satchel Lecita. Lecita was informed of the purpose of the visit.

Regarding the allegation, "Lack of supervision resulting in resident eloping from facility," it was alleged Resident One (R1) was found wandering outside of the facility premises, on several occasions, which resulted in a hospitalization. The LPA initiated the investigation on May 18, 2021; interviews were conducted, records were reviewed, and copies of pertinent information were obtained. According to the Administrator, R1 has wandered outside of the facility premises on two (2) occasions, and was immediately redirected by staff members. American Medical Response (AMR) records were requested and reviewed; the records reveal R1 was found outside of the facility premises on May 05, 2021 and on May 09, 2021 in a confused state of mind and unable to provide basic information. On May 05, 2021 R1 was found 0.2 miles away from the facility. On

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20210510172726

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
	VISIT DATE: 06/09/2021

NARRATIVE

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May 09, 2021 R1 was found 0.5 miles away from the facility. Records review was conducted; R1's Physician's Report for Residential Care Facility for the Elderly (RCFE) and Resident Appraisal reveal R1 is diagnosed with Dementia and has wandering behavior. This posed an immediate threat to R1's health and safety. Therefore, based on records and interview, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with Administrator Lecita and Licensee, Mary Jane Tolentino, in which this report was review and a copy provided, along with LIC 811 and Appeal Rights.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210510172726

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: 06/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2021 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	CARE OF PERSONS WITH DEMENTIA: In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.	1 2 3 4 5 6 7	According to Administrator, a fire clearance request will be submitted in order to receive approval for a locked perimiter.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records, the Licensee did not ensure safety measures to address wandering behaviors were in place. Interviews reported R1	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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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