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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530157
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:21:40 PM

Document Has Been Signed on 03/14/2025 03:21 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:AMISTAD ASSISTED LIVING AND MEMORY CARE HOMEFACILITY NUMBER:
335530157
ADMINISTRATOR/
DIRECTOR:		GARCIA, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:2308 MAVERICK CIRCLETELEPHONE:
(951) 310-4622
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 1DATE:
03/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administraor - Christopher Garcia TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Christopher Garcia and was granted entry to the facility. Licensed capacity is (6) current census (1). LPA was accompanied by Administrator Christopher Garcia to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a space office for resident/staff files. Furthermore, during facility tour, LPA observed a strong odor of urine in the kitchen/dining area.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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 5
Document Has Been Signed on 03/14/2025 03:21 PM - It Cannot Be Edited


Created By: Mary Rico On 03/14/2025 at 02:26 PM
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: AMISTAD ASSISTED LIVING AND MEMORY CARE HOME
FACILITY NUMBER: 335530157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation LPA Rico observed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will ensure the facility odorless and will send LPA Rico the in-service documentation.
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) and (record review)], the licensee did not comply with the section cited above by not having Administrator and S1 records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will send LPA Rico proof personnel records are maintianed at the facility.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/14/2025 03:21 PM - It Cannot Be Edited


Created By: Mary Rico On 03/14/2025 at 02:26 PM
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: AMISTAD ASSISTED LIVING AND MEMORY CARE HOME
FACILITY NUMBER: 335530157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (record review)], the licensee did not comply with the section cited above by not having a copy of S1 Health Screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will send a copy of S1 Health Screening to LPA Rico.
Type A
Section Cited
CCR
87355(j)
Criminal Record Clearance
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (record review)], the licensee did not comply with the section cited above by not having S1 criminal clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will send a copy of S1 criminal clearance to LPA Rico.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/14/2025 03:21 PM - It Cannot Be Edited


Created By: Mary Rico On 03/14/2025 at 02:26 PM
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: AMISTAD ASSISTED LIVING AND MEMORY CARE HOME
FACILITY NUMBER: 335530157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (record review)], the licensee did not comply with the section cited above in by S1 and Administrator not having documentation of their trainings which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will send a copies of staff training to LPA Rico.
Type A
Section Cited
CCR
87705(b)(1)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) and (record review)], the licensee did not comply with the section cited above by not having dementia training for S1 and the Administrator and which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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The Administrator stated they will send copies of staff training to LPA Rico.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/14/2025
NARRATIVE
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Record Review: LPA reviewed (1) resident files for admission agreements, updated physician reports, and needs and services plans. LPA audit (1) resident medications and (1) hospice file. LPA also reviewed (2) staff files for First Aid/CPR certification. During record review, LPA Rico observed the facility did not have S1 criminal clearance letter and Health Screening. In addition, S1 and the Administrator did not have staff training and dementia training documents. Furthermore, LPA Rico advised for the Administrator to receive technical support, the Administrator agreed for referral.

Based on the observations made during today’s visit, (6) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Christopher Garcia. Along with appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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