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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402510
Report Date: 09/16/2022
Date Signed: 09/16/2022 10:44:50 AM


Document Has Been Signed on 09/16/2022 10:44 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:NORTH SAN ANTONIO SENIOR CARE CORPFACILITY NUMBER:
366402510
ADMINISTRATOR:SCHWARCZ, ERICFACILITY TYPE:
740
ADDRESS:1738 NORTH SAN ANTONIO AVENUETELEPHONE:
(909) 931-2121
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 0DATE:
09/16/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Eric SchwarczTIME COMPLETED:
10:54 AM
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Licensing Program Analyst (LPA) Natalie Ibarra conducted an announced visit to conduct a final walk through of the facility prior to closure. The Department was notified of the facility closure by the Administrator Eric Schwarcz on 9/8/2022.

LPA Ibarra was informed all residents have been relocated and facility has been closed since 9/1/2021. LPA inspected the entire facility which included the bedrooms, bathrooms, dining area, kitchen and the backyard. There were no residents present, and there were no belongings of residents in the facility. Home is currently being used as a private residence. Administrator stated reason for closure is due to Covid 19.

The licensee will mail in the original license to CCLD at 1650 Spruce St. Suite 200, Riverside, CA 92507.

The effective date of closure will be 9/16/2022.

An exit interview was conducted and a copy of this report was discussed and provided to the Administrator.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Natalie IbarraTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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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