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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336301163
Report Date: 06/02/2026
Date Signed: 06/02/2026 09:29:49 AM

Document Has Been Signed on 06/02/2026 09:29 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
RIVERSIDE SE CC RO, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:WILBURN-POLK FAMILY CHILD CAREFACILITY NUMBER:
336301163
ADMINISTRATOR/
DIRECTOR:		CYNTHIA WILBURN-POLKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 714-9549
CITY:SAN JACINTOSTATE: CAZIP CODE:
92582
CAPACITY: 14TOTAL ENROLLED CHILDREN: 1CENSUS: 1DATE:
06/02/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Cynthia Wilburn-PolkTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On 06/02/26, Licensing Program Analysts (LPA) Kelli Waters arrived unannounced for an annual inspection. During the visit, Licensee Cynthia Wilburn-Polk, stated that she is pursuing other ventures and requested to go on inactive status. Present during the visit was licensee, an adult resident and one child in care. LPA provided licensee with LIC 9211 Request for Inactive Child Care License Status form.

LPA explained Inactive status and the Licensee agreed to the following:
  • Licensee will not provide child care for which a license is required until my license is reactivated.
  • Licensee will continue to pay the annual license fee by the annual due date of April 24th. Licensee understands that failure to pay the annual license fees will result in the closure of the facility.
  • Licensee will inform the Licensing Office (RO) of any changes in the inactive dates by submitting a new LIC9211, before the expiration date. Licensee understands an inspection is necessary prior to re-opening the facility and will contact or inform the assigned analyst or the “Duty Officer” prior to re-opening the facility to request an inspection.
  • Licensee will be in compliance with all licensing laws and regulations upon re-opening the facility, including but not limited to: Ensuring all adult staff and residents, including children who turn 18 during the inactive period, have criminal record clearances.
  • Licensee will ensure compliance with all new legislation and/or regulations.
  • Licensee will maintain current CPR, First Aid, and Mandated Reporter Certifications.
  • Licensee will maintain a current fire extinguisher, carbon monoxide, and functioning smoke alarms and/or detectors.


License will be inactive from 06/02/26 through 06/02/27 on the condition that fees remain paid.

An exit interview was conducted, a copy of this report, notice of site and appeal rights were reviewed with the licensee Cynthia Wilburn-Polk.
NAME OF LICENSING PROGRAM MANAGER: Carlos Martinez
NAME OF LICENSING PROGRAM ANALYST: Kelli Waters
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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