342701398-7-30-2025-27-AS-KVIA-DK3W4S-20250730165801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701398
Report Date: 07/30/2025
Date Signed: 07/30/2025 04:58:16 PM

Document Has Been Signed on 07/30/2025 04:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DREAMERS' HEARTH		FACILITY NUMBER:	342701398
ADMINISTRATOR/ DIRECTOR:	SUGANOB, JESSIE		FACILITY TYPE:	735
ADDRESS:	11859 AUTUMN SUNSET WAY		TELEPHONE:	(916) 225-8423
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95742
CAPACITY: 4		CENSUS: 4	DATE:	07/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Belinda Sibal		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 07/30/25. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). LPA met with Designee / House Manager, Belinda Sibal and a brief interview followed. LPA presented the Designee with a list of documents to be collected during the visit:

· LIC 500: Personnel Report

· LIC 308: Designation of Administrative Responsibility

· LIC 309: (for any LLC or Corp) if applicable

· LIC 402: Surety Bond, if applicable

· LIC 610E: Emergency Disaster Plan

· Copy of Liability Insurance

· Copy of Resident Roster

· Copy of the Administrator's Certification

LPA inspected resident rooms. All had the required furniture, furnishings and lighting to be in compliance at the present time.

The LPA inspected the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

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 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAMERS' HEARTH	FACILITY NUMBER: 342701398
	VISIT DATE: 07/30/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA inspected the bathrooms. Each contained soap, paper towels, and trash cans as required. Hot water was measured to ensure the temperature was between 105 and 120 degrees Fahrenheit in order to be in compliance. The hot water measured 117 degrees Fahrenheit at the time of this inspection. The 3 fire extinguishers were last serviced on 04/03/2025 by Sacramento Fire Extinguisher Company and were in compliance at the time of inspection.

The LPA observed medications were stored in a locked closet by the front door and inaccessible to residents in care. Medications were primarily the pill packs. LPA reviewed storage, dosing, and destruction procedures. LPA provided technical assistance regarding the administration and logging of PRN medications. A review of the First Aid kit by the LPA found it to be complete and in compliance.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. All screens and gutters were in good repair at the time of this inspection. There was also a sitting area for residents to enjoy that accommodated an umbrella for the required shade.

LPA observed an activity calendar, menu calendar, facility license, administrator's certificate, IF YOU SEE SOMETHING, SAY SOMETHING sign, along with resident and employee rights posters.

LPA conducted a sample file review. LPA conducted a review of 3 staff members during an earlier visit the same day. LPA conducted a resident file review. All were in compliance at the time of this inspection. LPA provided technical assistance regarding some of the required documentation.

According to the California Code of Regulations, Title 22, there was one deficiency observed during this inspection for reporting requirements since a resident was sent out for a change of condition and Community Care Licensing was not notified within the required 7 day period, This deficiency was cited on the LIC 809D page.

According to the California Code of Regulations, no other deficiencies were observed during this visit. A copy of this report was provided along with APPEAL RIGHTS and an exit interview was conducted with Belinda Sibal.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/30/2025 04:58 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 07/30/2025 at 03:25 PM

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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAMERS' HEARTH	FACILITY NUMBER: 342701398
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80061(b)

Reporting Requirements

(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a record review and interview, the licensee did not comply with the section cited above when they did not report a change of condition in their resident when they were brought home from the hospital, could not support their own weight, and were sent back to the hsoptial for further evalutation. This incident shoud have been reported to Licensing withing 7 days. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2025
	Plan of Correction
1 2 3 4	The Designee has stated that the missing incident report will be sent into Licensing by 08/04/25 and that both the Licensee and the Designee / House Manager will review Reporting Requirements and sign an atestation that they will be compliant going forward. This atestation will also be sent in to Licensing by 08/04/25 by fax or email to CCLASCPSacramentoRI@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4