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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:40:53 PM


Document Has Been Signed on 04/27/2022 03:40 PM - It Cannot Be Edited

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:
04/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Jane Tolentino, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene are conducting a case management visit to address deficiencies observed in conjunction with complaint investigation #18-AS-20220422170007. During this visit LPAs discovered two (2) staff members present without the proper clearances. Staff #1 (S1) and Staff #2 (S2) reported having the proper clearances but were unable to provide LPA with the required information. LPAs observed S1 and S2 depart the facility without issue.

Therefore, based on the observations made during today’s visit, the following deficiency was cited per Title 22, Division 6 of the California Code of Regulations. See LIC 809D. An exit interview was conducted and this reported was provided along with appeal rights and LIC 811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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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Document Has Been Signed on 04/27/2022 03:40 PM - It Cannot Be Edited

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: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2022
Section Cited

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Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...licensed facility: (1) Obtain a California clearance...as required by the Department. This requirement was not met as evidenced by:
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The Licensee did not obtain a criminal record clearance for Staff #1 (S1) or Staff #2 (S2) prior to S1 and S2 beginning employment. This poses an immediate health and safety risk to residents in care.

*Civil penalties were assessed
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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: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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