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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 12/15/2022
Date Signed: 12/21/2022 02:35:16 PM

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
04/15/2022 and conducted by Evaluator Arielle Pascua
COMPLAINT CONTROL NUMBER: 27-AS-20220415121941
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:
12:00 PM
MET WITH:Julian HawesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Staff are threatening resident.
INVESTIGATION FINDINGS:
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On 12/15/2022 at 12:00pm, 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.
Allegation: Staff are threatening resident.
Based on the interviews with the staff and R1 the facility has not removed the number of the staff that R1 was calling. The Staff member screens the calls from R1 and will not return the calls from her. As a result R1 will send text messages to that staff member who is currently out on leave as a result of an injury that was sustained on 2/23/22. The injury was caused by a kick from R1 and that injury required staff to be out on leave/disability.
The staff also confirmed that the facility would give R1, $25.00 dollars if she was behaving and the term "Good Girl Money" was used to describe this reward system.
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 4
Control Number 27-AS-20220415121941
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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LPA was able confirm that R1 was threaten with not getting her Good Girl Money if she continues to talk to the staff. LPA was unable to collaborate that R1 was threatened with being homeless.

LPA was able to locate an incident report dated 3/18/22 for the aggressive act from R1 that resulted in the injury to a staff member. The report stated that the investigation is pending and there is no other information regarding this incident.

This deficiency is addressed on the complaint investigation dated 6/22/22 and a plan of correction has been established. Therefore, there will not be a 9099D page for this substantiated personal rights finding.
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 4
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
04/15/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220415121941

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:
12:00 PM
MET WITH:Julian HawesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility shower is in disrepair
Staff are not meeting resident's toileting needs
INVESTIGATION FINDINGS:
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Allegation: Facility shower is in disrepair
Based on interviews with the Administrator the facility had an issue with the shower leaking from a small area that required a minor fix the shower was never out of commission and the residents could use the shower even as the repair was being completed. The facility has completed the minor repair and has not had any other issues with the shower or the bathroom since the caulking was completed.

Allegation: Staff are not meeting resident's toileting needs
Based on the resident’s individual service plan the facility is to provided verbal and physical prompts to assist the residents with assistance of daily living (ADL). The facility does not keep a log of these ADLs. Two residents in care are monitored while showering and toileting, however, R2 wear a depends and is changed as needed or R2 will notify staff that he needs assistance by taking the staff's hand and leading them to the restroom. LPA was unable to collaborate on a specific day that R2 had unchanged depends or that feces was left on their person.
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 4