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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880765
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:01:30 AM

Document Has Been Signed on 08/24/2023 11:01 AM - 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:ANITA CARE CENTERFACILITY NUMBER:
361880765
ADMINISTRATOR:JENNIFER BILIMORIAFACILITY TYPE:
735
ADDRESS:15121 RIVERSIDE LANETELEPHONE:
(951) 347-0887
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 5CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Homeranthony ClavecillaTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Rico met with Homeranthony Clavecilla explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, physical plant, and the clients in care. LPA Rico did not observe any safety hazards.

Based on the observations made during today’s visit, no deficiencies 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 Homeranthony Clavecilla
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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