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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602967
Report Date: 11/15/2024
Date Signed: 11/15/2024 11:27:10 AM

Document Has Been Signed on 11/15/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:DREAM CARE HOME LLCFACILITY NUMBER:
198602967
ADMINISTRATOR/
DIRECTOR:		CASTRO, MONAFACILITY TYPE:
740
ADDRESS:11838 163RD STTELEPHONE:
(562) 404-7010
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 6CENSUS: 6DATE:
11/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Administrator Mona Shelia Castro TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tyler Reyes and Luis Deleon conducted an unannounced Required 1 year inspection at the facility and met with Administrator Mona Castro and explained the purpose for todays visit.

The facility consist of 3 bedrooms,1 bathrooms, living room, dining room, kitchen, front and back yard with shaded area and attached garage used for storage and laundry services.

The facility had all postings at the front entrance, bathroom, and throughout the facility.

LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher in the kitchen. The water temperature was tested and measured at 111.5 degrees F. LPA received a copy of the facility liability insurance. LPA observed upon record review of medication resident #1 (R1) was missing Cough Syrup Liquid PRN (Take Five (5) ML By Oral Route Every 4 hours as Needed). Administrator Castro was unable to locate missing medication and stated a caregiver possibly disposed of medication.

Administrators certificate for Mona Sheila B Castro expires 09/01/2025

The Facility administrator was provided a copy of this licensing report along with appeal rights(LIC 9058), during the exit interview.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 11:27 AM - It Cannot Be Edited


Created By: Tyler Reyes On 11/15/2024 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DREAM CARE HOME LLC
FACILITY NUMBER: 198602967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review , the licensee did not comply with the section cited above LPA received a copy of the facility liability insurance. LPA observed upon record review of medication resident #1 (R1) was missing Cough Syrup Liquid PRN (Take Five (5) ML By Oral Route Every 4 hours as Needed). Administrator Castro was unable to locate missing medication and stated a caregiver possibly disposed of medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
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Administrator will esnure all residents medication is centrally stored and kept locked and safe. Administator shall order and replace missing medication immediately and provide proof to the department by POC Due Date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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