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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 12/15/2022
Date Signed: 12/16/2022 09:11:27 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220610095750
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:
12/15/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julian HawesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility bathroom is in disrepair.
INVESTIGATION FINDINGS:
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On 12/15/2022 at 10:00am, Licensing Program Analysts (LPAs) Arielle Pascua and Jason Lund arrived unannounced to this facility to conclude the investigation of the above allegations. LPA Pascua and Lund met with Facility Designated Representative, Ednita Gardenhire and explained the purpose of this visit. It was asked at this time to call the Facility Designated Administrator to let them know that CCL was present at this time. The purpose of this visit was to deliver complaint findings for the allegation above.
Current census was 4.
Initial 10-day visit to this facility on 05/10/2022. Licensing Program Analysts (LPAs) Arielle Pascua and Charlie Yang. LPA Pascua toured the main restroom. It was observed that the caulking around the bathroom was black and has not been maintained over time. LPA Pascua observed a dark brown hard water deposit stain under the bathtub faucet. Additionally, the bathroom was not in a clean and sanitary condition. Based on LPAs observation that was gathered, this posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20220610095750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2022
NARRATIVE
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As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220610095750

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:
12/15/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julian HawesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not to seek timely medical attention for resident.
Resident caused injury to another resident.
Resident(s) was hit by another resident.
INVESTIGATION FINDINGS:
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On 12/15/2022 at 10:30am, Licensing Program Analysts (LPAs) Arielle Pascua and Jason Lund arrived unannounced to this facility to conclude the investigation of the above allegations. LPA Pascua and Lund met with Facility Designated Representative, Ednita Gardenhire and explained the purpose of this visit. It was asked at this time to call the Facility Designated Administrator to let them know that CCL was present at this time. The purpose of this visit was to deliver complaint findings for the allegation above.
Current census was 4.
Allegation: Staff did not seek timely medical attention for resident.
The complainant stated that R1 harms himself daily. She stated that she was advised not to create a special incident report because the administrator was going to take care of the resident. Complainant also stated that she was told to call 911 because there are no major injuries to the resident at that time. Complainant could not provide any dates or times in which these incidents may have happened. LPA Pascua reviewed R1’s current IPP and it states that R1 has a history of pinching or hitting. It is unclear if the staff was able to seek timely medical attention for resident.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20220610095750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2022
NARRATIVE
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Allegation: Resident caused injury to another resident/Resident(s) was hit by another resident.

During the course of this investigation, LPA Pascua attempted to contact several staff members but was redirected to the Facility Designated Representative (FDR), Ednita Gardenhire. FDR, Gardenhire stated that she does not know of or has seen any of the residents hitting or causing injury to other residents. FDR, Gardenhire stated that R1 does have behaviors such as pinching or hitting. She stated that she believed that R1 does this because does not know how to express themself and will use the behaviors to let staff know that they are in need of something. Based on resident record review, it was learned that R1 has a history of behaviors that include pinching or hitting. FDR, Gardenhire also stated that R3 also has behaviors but is usually mitigated by staff in other ways. It is unclear if an incident did occur, was observed, or was not reported.

Based on information provided through interviews and records reviewed, this allegation is deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20220610095750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This was not met as evidenced by:
Based on LPA observation, the caulking around the bathroom bathtub was black
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The facility designated Administrator stated that these items will be repaired/cleaned. A statement of correction, along with photos of the items repaired/replaced, will be completed and submitted into CCL by the due date of 1/13/2023. POC was cleared at this visit 12/15/2022.
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and was not maintained over time and was not in a clean and sanitary condition. It was also observed that the bathtub exhibited a dark brown hard water deposit stain under the bathtub faucet. This poses an potential threat to the health, safety, and personal rights risk to the residents in care.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6