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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 03:18:07 PM

Document Has Been Signed on 03/14/2025 03:18 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator - Christopher Garcia TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced case management visit. LPA met with Administrator Christopher Garcia and explained the reason for the visit.

Community Care Licensing San Bernardino Regional Office received an Unusual Incident Report for R1. During record review, LPA Rico observed R1 incidents had occurred on 10/1/2024, 10/06/2024, 11/4/2024 and reported were to Community Care Licensing until 3/1/2025.

Based on observations today visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted, and this report was 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: 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)
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Document Has Been Signed on 03/14/2025 03:18 PM - It Cannot Be Edited


Created By: Mary Rico On 03/14/2025 at 12:40 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2025
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.
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Licensee stated they will provided a certified letter they have read and understood section 87211(a)(1).
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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 an immediate health, safety or personal rights risk to persons in care.
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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.
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)
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