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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603759
Report Date: 06/24/2023
Date Signed: 06/24/2023 12:10:24 PM


Document Has Been Signed on 06/24/2023 12:10 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:DAYBREAK VILLA EASTFACILITY NUMBER:
374603759
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1682 DAYBREAK PLACETELEPHONE:
(760) 781-1079
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 6DATE:
06/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rolando Corpuz, AdministratorTIME COMPLETED:
12:15 PM
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On June 23, 2023, at 6:50pm, Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility unannounced to conduct a annual inspection. LPA was greeted by Caregiver, Remedios Semon and the purpose of the visit was explained. Administrator Rolando Corpuz joined shortly. The facility is a one story five (5) bedroom, four (4) bathroom home. There is one bedroom shared by two (2) clients. A tour of the facility was conducted inside and out. The alarm system was tested. Hot water temperature was tested at 110.9 degrees Fahrenheit. Due to time constraints, LPA advised Administrator the inspection would have to be continued at another date.

On June 24, 2023 at 10:30am, LPA Shaw Ross returned back to the facility to complete the inspection, and was greeted by Administrator, Rolando Corpuz. Present at the facility were two (2) staff members and six (6) clients. LPA conducted staff and client interviews.
LPA reviewed staff and client records. Review of staff records indicate all staff have criminal record clearances and are appropriately associated to the facility. Staff files had the required documentation including First Aid Certifications and training documents that included recent trainings on June 16, 2023. Review of the facility training binder showed the following refresher trainings completed include: Alzheimer's, Emergency Disaster, Postural Supports, Restricted Conditions, Hospice, Reporting Abuse, Food Handling, Dementia, Fall Prevention and Medication training. LPA inspected medications and medications appear to be dispensed appropriately according to physician's orders. The outdoor space is free of hazard. Emergency drills are conducted quarterly. Fire extinguishers are charged.

During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided to the Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2023
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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