<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800003
Report Date: 07/27/2021
Date Signed: 07/27/2021 05:47:45 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
12/19/2019 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191219111821
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
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mary Jane Tolentino, LicenseeTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility window in disrepair
Staff did not provide privacy for resident
Staff did not provide comfortable temperature for residents

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit at Azzur Assisted Living LLC to deliver the findings of the investigation into the above allegations. The LPA was greeted by caregiver, Susan Dunn, and later met with Licensee, Mary Jane Tolentino. Tolentino was informed of the purpose of the visit.

Pertaining to the allegation, "Facility window in disrepair," it was alleged a window in Resident One's (R1's) bedroom had been broken and was not properly repaired by facility staff. The LPA initiated the investigation on December 26, 2019 by conducting a tour of the facility premises. The LPA observed one window to be broken in bedroom #8. The window was temporarily repaired with white poster board sheets, tape, and silicone caulk. A sign was posted on the broken window requesting the window not be opened and was dated December 20, 2019. According to Licensee, Mary Jane Tolentino, R1's window had been broken by unknown perpetrators in December 2019 and had not been fully repaired due to a pending law enforcement investigation. Third party interviews were conducted; it was reported there were two (2) incidences involving broken windows being
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 18-AS-20191219111821
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: 07/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
reported to local law enforcement on or around November 26, 2019 and December 08, 2019. Photographs were received showing the window continued to remain damaged until December 18, 2019, ten (10) days later. This posed an immediate health, safety and personal rights risk to the resident in care. Therefore, based on interviews and records review, this allegation is deemed SUBSTANTIATED. A citation will be issued.

Regarding the allegation, "Staff did not provide privacy for resident," it was alleged translucent curtains hung in R1's bedroom, which did not provide privacy for the resident. The LPA toured the facility and observed two (2) sets of curtains hung together in R1's bedroom, bedroom #8, on December 26, 2019. The two (2) sets of curtains blocked out all visibility from either side of the window. R1 was interviewed and reported there was previously only one (1) set of curtains, which were transparent and posed a privacy concern. Furthermore, photographs were obtained which revealed only one (1) set of curtains hung in R1's bedroom on or around December 18, 2019. The curtains were transparent, as the street could be viewed while the curtains were drawn together. According to Licensee, Mary Jane Tolentino, R1 did not report concerns to her about the curtains beint translucent. This posed an immediate personal rights violation. Therefore, based on interviews and records review, this allegation is deemed SUBSTANTIATED. A citation will be issued.

With regard to the allegation, "Staff did not provide comfortable temperature for residents," it was alleged the temperature registered at sixty-two (62) degrees Fahrenheit inside the facility, where R1's bedroom was located. The LPA toured the property, which has several buildings, and observed the temperature near R1's bedroom to register at seventy-one (71) degrees Fahrenheit. Photographs were obtained; it was revealed the temperature on or around December 18, 2019 registered at sixty-one (61) degrees. R1 was interviewed and reported the temperature inside the home was cooler than they preferred. According to Licensee, Mary Jane Tolentino, R1 did not report concerns to her about the temperature. This posed an immediate risk to the health, safety and personal rights of R1. Therefore, based on records review and interview, this allegation is deemed SUBSTANTIATED. A citation will be issued.

A finding that the complaint is substantiated means that the allegations are 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; this report was reviewed with Tolentino and a copy was 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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
12/19/2019 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191219111821

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
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mary Jane Tolentino, LicenseeTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff denied resident a shower
Lack of supervision resulting in inappropriate behaviors between residents
Staff did not provide adequate food supply
Staff does not have residents’ complete records on file
Staff did not provide appropriate bedding for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit at Azzur Assisted Living LLC to deliver the findings of the investigation into the above allegations. The LPA was greeted by caregiver, Susan Dunn, and later met with Licensee, Mary Jane Tolentino. Tolentino was informed of the purpose of the visit.

Pertaining to the allegation, "Staff denied resident a shower," it was alleged staff had denied showers to R1 and the resident was observed, on or around December 18, 2019, to be dirty, had stains on their shirt and had greasy hair. Staff/resident interviews were conducted. Staff reported R1 would receive showers from staff on occasion. It was also reported R1 would refuse showers when offered by staff. R1 was interviewed and reported they did not experience any difficulty in receiving showers while residing at the facility. R1 could not recall if they had ever refused to receive a shower from staff members. Records review was conducted; R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed R1 did not have the capacity to bath independently. Therefore, due to lack of information, this allegation is deemed UNSUBSTANTIATED at
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20191219111821
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: 07/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
this time.

Regarding the allegation, "Lack of supervision resulting in inappropriate behaviors between residents," it was alleged facility staff failed to properly supervise R1 and their roommate, which led to R1 being assaulted by their roommate on an unknown date. R1 was interviewed and reported they had been kicked by their roommate, Resident Two (R2), which resulted in bruises and difficulty walking. R1 could not report when the incidences occurred, why they occurred, and if they had been reported to staff members at the time. Licensee Tolentino reported there was no resident by the name provided. Therefore, based on a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

With regard to the allegation, "Staff did not provide appropriate bedding for resident," it was alleged facility provided R1 with a sheet and a very thin blanket on or around December 18, 2019. On December 26, 2019 the LPA toured the facility and observed R1's bed to have available the following: one (1) fitted sheet and two (2) blankets. R1 was interviewed; the resident reported they were cold on occasion and that no other blankets were provided to them. Licensee Tolentino R1 had spare blankets available to them. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Pertaining to the allegation, "Staff did not provide adequate food supply," it was alleged the facility was observed on or around December 18, 2019 to only have a large quantity of bologna. The LPA audited the food supply on December 26, 2019; the LPA observed more than nine (9) packages of bologna inside the freezer, along with packages of whole turkey, ground beef, ribs, and other meats. Canned food was also observed to be available during the audit. R1 was interviewed; the resident reported the facility does frequently serve meals with Bologna. R1 could not indicate the frequency staff would serve meals with Bologna, other than stating it was too frequent. Additional resident interviews were conducted; no reports were received regarding Bologna being served too frequently. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation, "Staff does not have residents’ complete records on file," it was alleged R1's Personal and Incidental (P&I) records could not be provided to the resident's authorized representatives on or around December 18, 2019. According to Licensee, Mary Jane Tolentino, R1's authorized representatives did not return to the facility to receive the requested reports. A records review was conducted; the Record of Client's/Resident's Safeguarded Cash Resources indicated R1 managed their own cash resources. According
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20191219111821
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: 07/27/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
to R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE), the resident is unable to manage their own finances. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Tolentino, in which this report was reviewed, and a copy provided.

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
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20191219111821
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: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents...This requirement was not met as evidenced by: Based on records review the
1
2
3
4
5
6
7
The window in bedroom #8 has been repaired. POC cleared.
8
9
10
11
12
13
14
Licensee did not ensure the facility was maintained in good repair. Interviews reported there were 2 incidences involving broken windows being reported on or around 11/26/19 & 12/08/19. Photos were received showing the window remained damaged until 12/18/19
8
9
10
11
12
13
14
Type B
07/27/2021
Section Cited
CCR
87468.2(a)(1)
1
2
3
4
5
6
7
ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES: ..residents in privately operated RCFEs shall have all of the following personal rights: To have a reasonable level of personal privacy in accommodations...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Additional curtains were hung in bedroom #8 prior to the LPA's visit on 12/26/2019.
8
9
10
11
12
13
14
Based on interviews & records review, the Licensee did not ensure a reasonable level of personal privacy was provided to R1. R1 reported the curtains were transparent & posed a privacy concern. Photos showed the curtains were transparent, as the street could be viewed while the curtains were drawn.
8
9
10
11
12
13
14
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20191219111821
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: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2021
Section Cited
CCR
87303(b)(1)
1
2
3
4
5
6
7
MAINTENANCE AND OPERATION: A comfortable temp. for residents shall be maintained at all times. The facility shall heat rooms...to a minimum of 68 degree F...This requirement was not met as evidenced by: Based on records review and interview, the Licensee did not ensure room was heated to at
1
2
3
4
5
6
7
Licensee stated she would submit a facility policy, indicating temperature checks will be checked weekly.
8
9
10
11
12
13
14
least 68 degrees F. Photos revealed the temp. on or around 12/18/19 registered at 61 degrees F. R1 reported the temp. inside the home was cooler than they preferred.
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 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
LIC9099 (FAS) - (06/04)
Page: 7 of 7