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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604084
Report Date: 01/30/2023
Date Signed: 01/30/2023 02:45:08 PM

Document Has Been Signed on 01/30/2023 02:45 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:AFFINITY RESIDENTIAL CAREFACILITY NUMBER:
374604084
ADMINISTRATOR:ASATYAR, MAKIZFACILITY TYPE:
735
ADDRESS:1610 HUMPHREY PLTELEPHONE:
(858) 231-0352
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 4CENSUS: 3DATE:
01/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Makiz Asmatyar, LicenseeTIME COMPLETED:
02:55 PM
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On January 30, 2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit for the purpose of conducting a complaint investigation. LPA met with Licensee, Makiz Asmatyar and explained the purpose of the visit.

During the visit, LPA interviewed staff and residents. LPA reviewed residents file and obtained copies of pertinent documents. No citation was issued during today’s visit.

An exit interview was conducted were this report was discussed with and provided to Makiz Asmatyar.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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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