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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603760
Report Date: 09/27/2023
Date Signed: 09/27/2023 03:19:20 PM


Document Has Been Signed on 09/27/2023 03:19 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 WESTFACILITY NUMBER:
374603760
ADMINISTRATOR:CORPUZ, ROLANDOFACILITY TYPE:
740
ADDRESS:1681 DAYBREAK PLACETELEPHONE:
(760) 737-6799
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 6DATE:
09/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Ronaldo Corpuz TIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/27/2023, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit to address a deficiency observed during investigation of complaint control #18-AS-20230922142852. LPA met with Administrator Ronaldo Corpuz who was informed of the purpose of the visit.

During LPA's visit at the facility on 9/27/2023, a record review revealed that Staff #1 is not associated to the facility. As a result, LPA assessed a civil penalty.

An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Corpuz along with a Confidential Names List (LIC811), LIC809-D, LIC421BG and Appeal Rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/27/2023 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 WEST
FACILITY NUMBER: 374603760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
87355(e)(3)

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87355(e) (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r)...
This requirement was not met as evidenced by:
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Licensee stated the facility will request a transfer of a criminal record exemption for Staff #1 on 9/28/2023. Proof of correction to be submitted to LPA by close of business on 10/6/2023.
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A record review revealed that Staff #1 present during LPA's visit, is not associated to the facility.
This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
LIC809 (FAS) - (06/04)
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