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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700080
Report Date: 04/15/2025
Date Signed: 04/15/2025 01:55:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/15/2025 01:55 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:COMFORCARE HOME CARE-RANCHO CUCAMONGAFACILITY NUMBER:
364700080
ADMINISTRATOR/
DIRECTOR:		DAVIS, SHAYFACILITY TYPE:
300
ADDRESS:600 N MOUNTAIN AVE, STE B-200TELEPHONE:
(909) 932-1110
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: CENSUS: DATE:
04/15/2025
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rachel Davis, OwnerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Enforcement Analysts (EAs), Jane Cong-Huyen and Mila Quinto, with the Home Care Services Branch (HCSB) conducted an onsite inspection for the purpose of a Required 2 Year Licensing visit. The EAs met with owner, Rachel Davis. EAs observed posting of the current license and operating business hours: 9am-2pm, Tuesdays and Thursdays.

During the inspection, the EAs reviewed personnel records for staff and HCA staff including fingerprint clearance, HCA Registry, Tuberculosis (TB), and required training. The HCO’s business records including document for designee (HCS308) in the absence of the licensee, insurance, bond and worker's compensation requirements were also reviewed during the visit.

EAs Cong-Huyen and Quinto found the HCO in compliance and no deficiencies were cited. An exit interview was conducted, a copy of this report (HCS809), was provided to the owner, Rachel Davis, via email.
NAME OF LICENSING PROGRAM ANALYST: Jane Cong-Huyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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