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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366406663
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:56:34 AM


Document Has Been Signed on 08/22/2023 10:56 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:EMJAY'S HOME CAREFACILITY NUMBER:
366406663
ADMINISTRATOR:SWANSON, JOSEPHINE D.FACILITY TYPE:
740
ADDRESS:11540 PECAN WAYTELEPHONE:
(909) 796-9754
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:6CENSUS: 0DATE:
08/22/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Edgar Echaluse, LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an announced facility closure visit. LPA arrived and met with Edgar Echaluse, Licensee. Community Care Licensing Division (CCLD) received notification of facility non-operation effective 4/01/23.

LPA Malcore toured the facility and observed no residents’ belongings and no residents in care. Licensee Echaluse informed LPA, facility has not had residents since 2019. Licensee stated reason for closure as no longer interested in maintaining a license.

CCLD Regional office received original license on 6/20/2023. The effective date of closure is 8/22/2023.

An exit interview was conducted where this report was discussed, and a copy of this report was provided to the Licensee at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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