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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 364700166
Report Date: 07/03/2026
Date Signed: 07/03/2026 12:35:30 PM

Document Has Been Signed on 07/03/2026 12:35 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: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:
07/03/2026
Post LicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Miracle Robert, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Enforcement Analyst (EA), Jane Cong-Huyen, with the Home Care Services Branch (HCSB) conducted a virtual visit for the purpose of a biennial inspection. EA met with the licensee, Miracle Robert. Per virtual tour of the facility, EA observed the posting of the license and operating business hours. Business operating hours are from 8:30am - 5:30pm, Monday through Friday.

The licensee stated the HCO does not have any clients or HCAs at this time. During the inspection, EA discussed and reviewed the requirements for personnel records for Home Care Aides (HCAs) including fingerprint status, HCA registry status, Tuberculosis (TB), and required training(s). EA also reviewed the HCO’s business records for insurance requirements.



EA Cong-Huyen found the HCO in compliance and no deficiencies were cited. An exit interview was conducted, and a copy of this report (HCS809) was provided to the licensee, Miracle Robert, via email.
NAME OF LICENSING PROGRAM ANALYST: Jane Cong-Huyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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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