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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 04/05/2023
Date Signed: 04/07/2023 08:03:48 AM

Document Has Been Signed on 04/07/2023 08:03 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:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julian Hawes TIME COMPLETED:
01:30 PM
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On 04/05/2023 at 11:00am, Licensing Program Manager (LPM) Emerita Curiel and Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPM Curiel and LPA Pascua were greeted by Facility Designated Administrator, Julian Hawes and explained the purpose of the visit. There were three other staff members present during the course of this visit Iboni James, Alma Moyamoy, and Jada Hull. Current Census was 4. 1 out of 4 resident were out at their respective day programs at this time.

This facility is licensed to serve 4 residents at this time. This facility is also vendorized by Valey Mountain Regional Center to served and accept Level 4I residents.
LPA and LPM review 5 staff files. All staff files were current and up to date. LPA and LPM reviewed 4 resident files. A resident files were current and up to date. No residents were interviewed at this time due to medical conditions or due to the resident sleeping. The administrator has a current and active Administrator certificate #6052806735 and expires on 07/29/2023.

LPA observed a locked centralized stored medication cabinet located in the living room. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
A tour with FDA Hawes was conducted. Fire extinguisher located in the living room was serviced by Jorgensen Co on 06/15/2022.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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: 04/05/2023
NARRATIVE
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A tour of the garage was conducted. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
A tour of the 3 resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.
A tour of the bathrooms was conducted. Hot water temperature was taken in 2 bathrooms. Hot water temperature in bathroom 1 was measured to be at 128.3. Hot water temperature in bathroom 2 was measured to be in 126.5. LPA informed Facility Designated Administrator that the hot water temperature was above the required range.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.


Exit Interview was conducted and a copy of this report and appeals rights were emailed to the Facility Designated Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2023 08:03 AM - It Cannot Be Edited


Created By: Arielle Pascua On 04/05/2023 at 01:18 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above 80088(e)(1) by not ensuring that the hot water temperature was not maintained between 105-120 degrees F. LPA took the water temperature of two bathrooms and were observed to be 128.3 and 126.5. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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Licensee agrees to adjust the water temperature during the course of the visit. Licensee agrees to check temperature for the next 7 days and send in a log to the LPA.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023


LIC809 (FAS) - (06/04)
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