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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004468
Report Date: 05/03/2022
Date Signed: 05/03/2022 02:49:44 PM

Document Has Been Signed on 05/03/2022 02:49 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:DREAM THEATRE INC.FACILITY NUMBER:
317004468
ADMINISTRATOR:WHEELER, MICHELLEFACILITY TYPE:
775
ADDRESS:501 DEREK PLACE, SUITE 160TELEPHONE:
(916) 780-2090
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 45CENSUS: 0DATE:
05/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Michelle WheelerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 5/3/22 to conduct a Annual Inspection utilizing the infection control domain guidance. LPA met with the Director and explained the purpose of the visit. Prior to initiating the inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by caregiver upon entering the facility.

LPA toured the interior of the facility together with Michelle to ensure health and safety of residents in care. . In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Director covered the infection control topics and facility was found to be in substantial compliance at this time.

LPA will forward links to additional information.

LPA requested Administrator submit: client roster and staff roster to CCL by 7/1/22.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2022
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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