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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700166
Report Date: 06/26/2026
Date Signed: 07/03/2026 08:21:48 AM

Document Has Been Signed on 07/03/2026 08:21 AM - 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:DAVINA HOME CARE LLCFACILITY NUMBER:
364700166
ADMINISTRATOR/
DIRECTOR:		ROBERT, MIRACLEFACILITY TYPE:
300
ADDRESS:13612 KINGS CANYON CTTELEPHONE:
(909) 434-2126
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: CENSUS: DATE:
06/26/2026
OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Miracle Robert, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Home Care Services Branch (HCSB), Enforcement Analyst (EA), Jane Cong-Huyen spoke to licensee, Miracle Robert, to conduct a telephone pre-inspection interview. Licensee confirmed HCO Information. The HCO is due for a biennial visit and has agreed to a virtual inspection visit with EA.

The virtual inspection visit is scheduled for Friday 7/3/2026 @ 9:30am via Microsoft Teams. EA emailed the HCO with specific instructions regarding the virtual licensing inspection and the required documentation for the HCO to submit to EA via email before/by Tuesday 6/30/26.

The HCO will be receiving this report via email. HCO will send report back to EA with signature as soon as possible or by COB Monday 6/29/26 to confirm the virtual inspection visit.

NAME OF LICENSING PROGRAM ANALYST: Jane Cong-Huyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
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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