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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800003
Report Date: 07/15/2022
Date Signed: 07/15/2022 10:51:00 AM


Document Has Been Signed on 07/15/2022 10:51 AM - 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: 19DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Liberty Almazon - Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Liberty Almazon and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Liberty Almazon, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and 4 of the 7 bathrooms were stocked with hand soap and paper towels. LPA Colvin observed the two isolation room bathrooms, the guest/visitor bathroom, and one bathroom in building #2 to be missing paper towels. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note during today's inspection, as staff corrected the issue during the visit and the isolation bathrooms are not in use at this time. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the facility office. LPA Colvin observed the facility have an adequate supply of PPE. LPA Colvin went over the various recommended training for facility staff with Administrator Liberty Almazon in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Liberty Almazon confirmed that staff have been fit tested. LPA Colvin observed during todays visit that at least two staff were not wearing a face covering of any kind. LPA Colvin will be issuing a TA Advisory Note as all persons are to wear face coverings while at the facility. LPA Colvin additionally inquired about sign-in logs and screenings of visitors. The Administrator informed LPA Colvin that while guests are told to come to the office (in Building #1) to sign in, that they are not screen for COVID symptoms, and only attest to being negative from COVID-19.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


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
VISIT DATE: 07/15/2022
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LPA Colvin will be issuing a TA Advisory Note for staff not screening visitors for COVID-19 symptoms prior to entry to the facility. Additionally, LPA Colvin observed that there is no direct entry from the outside to the office (where guests sign in), and that visitors could enter the facility from numerous points and potentially avoid signing in, though there are posting advising guests to go to the office to sign in. LPA Colvin will be issuing a TA Advisory Note as the facility should be taking further measures to ensure all visitors enter through a single location so that they may be screened before entry and sign in. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. The Administrator confirmed that residents are being screened daily and COVID tested on a weekly basis.

Other Issues:
During LPA Colvin's inspection, two additional items outside of Infection Control were observed which need to be addressed. Upon LPA Colvin's entry to Building #1, LPA Colvin observed a sign dated 6/29/22 on the door of a shower room stating not to use the room for showering or getting water, as there is a leak. LPA Colvin inquired about this with the Administrator and she confirmed that the shower is not to be used at this time due to the leak, and that the Licensee was made aware of the problem. It has been over two weeks since the date on the sign and the shower room is still out of order. Deficiency cited. During the tour of the facility, LPA Colvin observed numerous discarded items around the back of Building #2 and the storage shed. Items included mattresses, a Hoyer Lift, rugs, and other furnishings. LPA Colvin inquired about the discarded items and the Administrator confirmed that they are being thrown out, but that it is taking time to get them hauled away. Deficiency cited. Lastly, LPA Colvin observed that Administrator Liberty Almazon was not listed on Licensing profile for the facility (or Guardian's Roster) as the Administrator, but rather as just an employee. LPA Colvin inquired as to if the Licensee had notified Licensing of the change of Administrator, and if the required documentation had been submitted. The Administrator showed LPA Colvin a letter which confirmed that the documents to change the Administrator had been submitted, but that they were returned as one of the items needed the Licensee's signature. The Administrator stated that they had resubmitted the paperwork but have not received a response back. LPA Colvin advised that she will follow up with the office on the status of this.

An exit interview was conducted with Administrator Liberty Almazon and a copy of this report, LIC9102 TA Advisory Notes, and LIC809D was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/15/2022 10:51 AM - 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: 07/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation: (a) 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, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 area of the facility, which poses a potential personal rights risk to persons in care. LPA Colvin observed that there was trash/discarded items (rugs, mattresses, furniture) meant for disposal piled around the side of Bulding #2 by the storage shed. Administrator confirmed that they are waiting for items to be taken away.
POC Due Date: 07/29/2022
Plan of Correction
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premises in a healthful manner. Licensee to provided LPA Colvin with photographic proof of items removed from area, as well as Statement of Certification that items were removed from premises and disposed of.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 shower rooms, which poses a potential health risk to persons in care. LPA Colvin observed that the shower room in Building #1 was out of order, as evidenced by a sign placed on the door dated 6/29/22. Administrator confirmed with LPA Colvin that they are unable to use the shower room due to the repairs needed, and that the Licensee was informed of the issue.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee agrees to have the shower room in Building #1 repaired. Licensee to provide proof of repair (such as invoice) to LPA Colvin by Plan of Correction Date of 7/29/22.

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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7