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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604084
Report Date: 12/01/2025
Date Signed: 12/02/2025 04:12:21 PM

Document Has Been Signed on 12/02/2025 04:12 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AFFINITY RESIDENTIAL CAREFACILITY NUMBER:
374604084
ADMINISTRATOR/
DIRECTOR:		ASATYAR, MAKIZFACILITY TYPE:
735
ADDRESS:1610 HUMPHREY PLTELEPHONE:
(858) 231-0352
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 4CENSUS: 2DATE:
12/01/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Makiz AsmatyarTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 12/1/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of issuing citations for deficiencies observed during the investigation into complaint control number 18-AS-20251028101412. LPA Flores met with Administrator Makiz Asmatyar and explained the purpose of the visit.

A records review of Client #1 (C1) preplacement referral revealed that C1 may forget to administer their prescribed medication which results in behavioral changes. A record review of C1’s physician report revealed that C1 requires assistance and supervision with medication management which includes the control and custody of medication. Interviews with C1 and Staff #1 (S1) reported that when C1 had overnight stays at their responsible persons home, C1 was given their medication by S1 without a lockbox in place despite physicians orders advising that C1 requires assistance with administering and storing their medication. Interviews with C1 and S1 reported that when C1 was at their responsible persons home, C1 would at times forget to administer their medication as prescribed. C1 and S1 further reported that C1 left the missed dosage of medication in the container that was provided to C1 by S1. C1 would return to the facility and provide S1 with the missing dosage. Interviews with S1 reported that S1 stored the missed dosage of medication in a container that was not the original packaging/container and S1 would administer C1’s medication as prescribed from the medication that was stored outside of the original packaging. Based on record review, observations, and interviews, deficiencies will be issued in accordance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights was discussed with and provided to Administrator Makiz Asmatyar.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Valerie Flores
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/02/2025 04:12 PM - It Cannot Be Edited


Created By: Valerie Flores On 12/02/2025 at 11:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2025
Section Cited
CCR
80075(k)(5)(6)

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(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container. (6) No medications shall be transferred between containers. This requirement was not met with evidence by:
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Administrator agreed to provide the department a sign afadavit agreeding that they have read Title 22 Section 80075 by Close of Business on 12/2/2025. The signed afadavit will be forwarded to LPA via email.
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(1) one out of (1) client's missed dosages of medication were stored in a seperate container outside of its original container and were administer to Client #1 (C1) as needed from the medication that was store outside of the original container.
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Type A
12/02/2025
Section Cited
CCR80075(j)(2)

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(j) Medications shall be centrally stored under the following circumstances: (2) Any medication determined by the physician to be hazardous if kept in the personal possession of the client for whom it was prescribed. This requirement was not met with evidence by:
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Administrator agreed to enroll in an out-service training on medication management. Proof of enrollment is due by Close of Business on 12/2/2025. The Plan of Correction cannot be fulfilled until the Administrator provides proof of training completion via email to LPA by
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(1) one out of (1) one clients were given control of their medication despite physicians orders advising that Client required assistance with storing and administering their own medication.
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Close of Business on 12/16/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Valerie Flores
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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