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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530157
Report Date: 12/20/2024
Date Signed: 12/20/2024 02:18:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/27/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241127122555
FACILITY NAME:AMISTAD ASSISTED LIVING AND MEMORY CARE HOMEFACILITY NUMBER:
335530157
ADMINISTRATOR:GARCIA, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:2308 MAVERICK CIRCLETELEPHONE:
(951) 310-4622
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 1DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator - Christopher GarciaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not abide to admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Christopher Garcia and explained the purpose of the visit. The investigation consisted of staff interviews and record review.

For the allegation,Staff did not abide to admission agreement.

During staff interviews, Administrator informed LPA that R1 had moved into the facility on 10/1/2024. R1’s family made a payment of 6,500 on 10/1/2024 for the month of October 2024. On 10/18/2024 R1 had moved out of the facility and personal belongs were also removed. In addition, Licensee provided reimbursement of an amount of 187.22 to R1's family.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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 56-AS-20241127122555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AMISTAD ASSISTED LIVING AND MEMORY CARE HOME
FACILITY NUMBER: 335530157
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
HSC
1569.652(c)
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1569.652(c) Termination of admission agreement upon..; removal of resident’s property; refund of fees paid.. and refund(c)A refund of any fees paid in advance ..removed from the. resident paid the fees.. personal property is ..
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Licensee stated they will send LPA proof they have provided R1's family correct reimbursement. In addition, proof they have read and understood regulation.
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Based on interview and record review, the licensee did not comply with the section cited above by not providing correct reimburstment which poses a potential health, safety or personal rights risk to persons in care.
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POC due date date 12/27/2024
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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: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20241127122555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: AMISTAD ASSISTED LIVING AND MEMORY CARE HOME
FACILITY NUMBER: 335530157
VISIT DATE: 12/20/2024
NARRATIVE
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During record review, the facility did not issue a complete reimbursement. R1’s family should receive the correct reimbursement. The reimbursement is calculated after resident’s personal property has been removed from the facility from 10/1/2024 through 10/18/2024 without charging for additional staffing. Therefore, the facility did not abide to admission agreement.

Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because of the preponderance of evidence the standard has been met.



During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Administrator Christopher Garcia, along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3