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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:12:55 PM

Document Has Been Signed on 04/29/2024 12:12 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:DREAM CAREFACILITY NUMBER:
502700754
ADMINISTRATOR/
DIRECTOR:		NORMA BORGESFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Norma Borges TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 04/29/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility House Manager, Kenroy Anderson and explained the purpose of the visit. LPA asked that FHM Anderson call the Facility Designated Administrator (FDA), Norma Borges to inform them that CCL was present. There was one other staff member present, Nicolette Taylor. Shortly after, LPA met with FDA Borges. This purpose of this visit was to conduct an annual visit.
Current Census was 3. 1 out 3 residents were out at their respective day program.
A brief interview with FDA Borges was conducted.
This facility is licensed to serve 4 residents at this time. This facility is also vendorized by Valley Mountain Regional Center to served and accept Level 4I residents.
LPA reviewed 5 staff files and 3 resident files. It was observed that 4 out 5 staff files did not have a complete personnel report. 3 out 5 staff members did not have TB tests that were conducted within 1 year prior or 7 days after of their hire date. It was also observed that 1 out 5 staff members did not have background association to the facility. The facility administrator has a current administrator certificate #6066265735 and expires on 06/01/2025.
A tour of the facility was conducted. It was observed that 2 residents were sleeping in their respective rooms.
PA observed a locked centralized stored medication cabinet located in the living room. It was learned that this facility now uses an Electronic Medication Administration Record. 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.
Fire extinguisher located in the living room was serviced by Jorgensen Co on 06/09/2023. Smoke Detectors and carbon monoxide was observed to be functional and in good repair. The last fire drill was conducted on 04/24/2024.
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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754
VISIT DATE: 04/29/2024
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 was taken to ensure that it was between 105-125 of 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. It was observed that there was a metal piece that was connected the handle of the gate to a metal screw connected to the fence. LPA notified FDA Borges that the fence cannot be locked at any time. It was stated that the fence needed to be fixed and would be fixed tomorrow. LPA asked that they take the metal piece off, LPA observed a staff member, Kenroy Anderson remove the metal piece.

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.
  • Facility staff was informed an immediate civil penalty of $100 was assessed for a violation of section 80019(e)(3) on 04/29/2024.

  • Facility staff was informed an immediate civil penalty of $1,000 was assessed for a violation of section 80020(a)a Section 04/29/2024.


Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility staff Norma Borges. An exit interview was held, and a copy of the report was provided in-person.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/29/2024 12:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 04/29/2024 at 11:26 AM
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: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not ensure that S1 did not have criminal record clearance to this facility. LPA observed that S1 did not have association to this facility at this time. A review of Guardian and LIS was checked and did not have S1 in the system. This poses an immediate health, safety and personal rights risks to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee shall associate S1 to the facility by the POC date. A immediate civil penalty of $100 provided.
POC was cleared during this visit.
Type A
Section Cited
CCR
80020(a)
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee comply with the section cited above by not ensuring that the side exit was not free of any obstruction. LPA observed a large metal piece connecting the handle of the fence to a screw which did not allow for the fence to open. This is an immediate health, safety, and personal rights risks to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee shall provide a statement of correction and acknowledgement by the POC date. LPA observed staff member remove the metal piece during the visit. An immediate civil penalty of $1,000 was provided due to a repeat violation.
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2024 12:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 04/29/2024 at 11:34 AM
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: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80065(g)(1)
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 3 out 5 staff members did not have a TB test done conducted 1 year prior to or seven days after employment. LPA reviewed 5 staff files of which had 3 staff files did not have a TB test within 1 year prior to or seven days after employment.
POC Due Date: 04/30/2024
Plan of Correction
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A statement of correction must be provided to the LPA by the POC date.
Copies of all staff TB tests must be provided to the LPA after completion.
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


LIC809 (FAS) - (06/04)
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