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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 12/09/2021
Date Signed: 12/13/2021 09:58:46 AM

Document Has Been Signed on 12/13/2021 09:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DREAM CAREFACILITY NUMBER:
502700754
ADMINISTRATOR:HAWES, JULIANFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Whitney MontijoTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 12/09/2021 by LPA Charlie Yang. This LPA was met by the facility designated Administrator Whitney Montijo who was briefly interviewed.
This facility is licensed to accept and retain up to (4) residents. This facility is vendorized through Valley Mountain Regional Center for a Level 4I home at this time.
Current census was 4 residents.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Supplies were observed to be sufficient and able to meet the needs of the residents at this time.
Food supply was reviewed for adequate (2) day perishable and (7) day nonperishable quantities at this time. Pantry area was reviewed.
Living area, dining area, and all other areas designated for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Medication cabinet, located in office area, was reviewed. First aid kit was observed to be present and contained all of the required components at this time.
Fire extinguisher, located in office area, was observed to have been annually inspected on 06/01/2021 by the local fire extinguisher company and in compliance at this time.
Laundry area was toured. Cabinet, storing cleaners and detergents, was observed to be locked and made inaccessible to the residents at this time.
Garage area was toured. It was observed to be furnished and maintained as another area designated for resident use.
A tour of the facility exterior grounds was conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754
VISIT DATE: 12/09/2021
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A review of the facility perimeter fence and side gate was conducted.
Linen closet, located in resident restroom, was observed to be stocked with sufficient towels and linens in order to meet the needs of the residents at this time.
The following forms and documents were requested by this LPA to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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