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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 11/16/2023
Date Signed: 11/17/2023 09:05:56 AM

Document Has Been Signed on 11/17/2023 09:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DREAM CAREFACILITY NUMBER:
502700754
ADMINISTRATOR:NORMA BORGESFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
11/16/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Andrea RushTIME COMPLETED:
03:30 PM
NARRATIVE
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On 11/16/2023, Licensing Program Analysts (LPA) Arielle Pascua arrived unannounced to this facility to conduct a quarterly non-compliance visit. LPA were greeted by House Manager, Andrea Rush and explained the purpose of the visit. It was learned that the FDA was out on vacation at this time. There was one other staff member present, Benjamin Nutall
Current census was 3. 1 out 3 residents were out of the facility at this time.

The purpose of this visit is to conduct a quarterly visit in response to a Non-Compliance meeting that was conducted with the facility on 07/11/2023.

A tour of the facility was conducted.
LPA toured 3 resident bedrooms. One resident bedroom is a share bedroom with an adjoining bathroom. All furniture and furnishing was observed to be in compliance at this time. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPAs observed laundry room where it was observed that detergent, laundry room and all cleaning supplies were locked and made inaccessible at this time. Knives were observed to be locked and made inaccessible. A tour of the bathrooms were conducted, hot water temperature was taken to ensure regulatory requirements. A tour of the living room, garage, office, and all other areas intended for resident use was conducted.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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