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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425515
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:14:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/20/2021 12:14 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:DAYBREAK CARE HOMEFACILITY NUMBER:
366425515
ADMINISTRATOR:CALDERON, GRACIELAFACILITY TYPE:
735
ADDRESS:15446 DAYBREAK LANETELEPHONE:
(909) 452-7178
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY: 6CENSUS: DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:TIME COMPLETED:
12:15 PM
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On 8/20/2021 at approximately 12:00 PM, Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct an annual inspection with an emphasis on infection control.

LPA Gardner rang the facility doorbell several times but did not receive an answer. LPA Gardner could hear the doorbell ringing from inside the facility and observed no vehicles parked in the driveway. This annual inspection would be rescheduled.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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