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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366403161
Report Date: 09/16/2022
Date Signed: 09/16/2022 10:10:48 AM


Document Has Been Signed on 09/16/2022 10:10 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 IIFACILITY NUMBER:
366403161
ADMINISTRATOR:SCHWARCZ, ERICFACILITY TYPE:
740
ADDRESS:938 W. 22ND STREETTELEPHONE:
(909) 931-2123
CITY:UPLANDSTATE: CAZIP CODE:
91784
CAPACITY:6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Eric SchwarczTIME COMPLETED:
10:13 AM
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Licensing Program Analyst (LPA) Natalie Ibarra conducted an unannounced visit to conduct an annual inspection. LPA was greeted and allowed entrance by caregiver Mona Ahme. Administrator Eric Schwarcz was notified and arrived shortly after. Administrator accompanied LPA on a tour of the facility.

LPA Ibarra toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Administrator. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, hand washing station, and a symptom check. The staff working at the facility were all properly wearing face masks. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Ibarra requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the garage. The facility has a full thirty (30) day supply of PPE such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer. LPA observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, the facility is meeting operational requirements.

No deficiencies were cited per Title 22, Division 6, of the California Code of Regulations

An exit interview was conducted and a copy of this report was provided and discussed with 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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