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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604084
Report Date: 12/02/2025
Date Signed: 12/03/2025 08:22:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/03/2025 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20251103102837
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: 2DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator Makiz AsmatyarTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide an accurate dosage of medication to resident
INVESTIGATION FINDINGS:
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On 12/2/2025, Licensing Program Analyst (LPA) Valerie Flores made an unannounced visit to the facility for the purpose of delivering investigative findings into the allegation listed above. LPA met with Administrator Makiz Asmatyar and explained the purpose of the visit. The investigation consisted of interviews, observations, and records review.

Information received alleged that Staff #1 (S1) did not provide an accurate dosage of medication to Client #1 (C1). Interview with Staff #1 (S1) and C1 reported that on the night of 7/4/2025, C1 decided to stay the night at their responsible person’s home. C1 did not advise staff that C1 was choosing to stay the night and would not be returning to the facility. Interview with S1 reported that S1 dispensed C1’s medication into a clear cup and left the medication on the dining table believing that C1 would be returning back to the facility soon. S1 further reporting hearing someone walk through the front door and believed it to be C1 but did not visually see C1 walk through the door.
(Continue to LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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 3
Control Number 18-AS-20251103102837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AFFINITY RESIDENTIAL CARE
FACILITY NUMBER: 374604084
VISIT DATE: 12/02/2025
NARRATIVE
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(Continuation from LIC9099)

Interview with C1 reported that they never returned to the facility on the night of 7/4/2025. C1 reported returning the morning of 7/5/2025. When C1 returned, C1 walked to the dining room and observed their medication dispensed into a clear cup and administered their medication believing it to be C1’s morning dose of medication. C1 reported that shortly after taking the medication on the dining table, S1 dispensed the morning medication. C1 alleges that they advised S1 of already taking their medication and S1 ignored C1 account and insisted on C1 taking the medication. Interviews with S1 reported that S1 was not made aware of the medication error until C1 advised S1 of what occurred approximately 1 hour after taking the second dosage of medication. Interviews with S1 reported that they immediately informed C1’s responsible person, poison control, and C1’s psychiatrist. S1 and C1 corroborated that staff monitored C1 for 24 hours and were not given their prescribed medication on 7/6/2025 as requested by C1’s psychiatrist. The facility does not maintain documents or written order advising facility staff to withhold the medication temporarily. A records review conducted of C1’s medication administered on 7/5/2025 revealed that C1 was administered the evening medication despite there being an error with the morning medication. Interview with S1 reported that the medication was administered as prescribed on 7/5/2025 as the facility staff did not receive a response with instructions from C1’s psychiatrist and S1 was advised by poison control that the dosage did not merit the situation to be an emergency as it was not a high enough dosage to be considered an overdose. A records review conducted of the facility’s incident reports confirmed S1 and C1’s account of their being a medication error. Although the timeline of when C1 advised S1 of the medication error did not corroborate, there is substantial amount of evidence that confirms C1 was given double dose of their prescription medication due to lack of care and supervision. Through observations, LPA observed sticky note paper on a center piece located on the dining room table. Each sticky note had the clients name along with a small clear container. Interview with C1 verified that medications are dispensed into the clear cup and are left on the table for clients to administer. Therefore, the allegation of staff did not provide an accurate dosage of medication to resident 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. California Code of Regulations Title 22 is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the LIC9099, LIC9099C, LIC 9099D, and appeal rights were reviewed and provided to Administrator Makiz Asmatyar.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20251103102837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: AFFINITY RESIDENTIAL CARE
FACILITY NUMBER: 374604084
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This was not met with evidence by: (1) one out of (1) one client was not provided care and supervision as needed during administering of Client #1 (C1)
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Administrator agreed to have all medication handling staff to enroll and complete an out-service training on medication handling. Proof of enrollment is due by Close of Business on 12/3/2025. The Plan of Correction cannot be fulfilled until the Administrator provides
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medication as the medication was left unattended on the table.
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proof of training completion via email to LPA by Close of Business on 12/17/2025.
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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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3