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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 01/27/2023
Date Signed: 01/27/2023 06:23:40 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
02/09/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220209101935
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:
01/27/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Julian HawesTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident’s hygiene is not being met
Facility is in disrepair
Facility is malodorous
INVESTIGATION FINDINGS:
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On 1/27/2023 at 1:00pm, Licensing Program Analysts (LPAs) Arielle Pascua and Jason Lund arrived at this facility unannounced for a complaint visit. LPAs were greeted Facility Designated Administrator, Julian Hawes and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegations above. There were 3 other staff members present at the facility, Bea Esquivel-Valdez, Alma Moyamoy, and Geraldo Vazquez.

Current census was 4. 1 out 4 residents were at their respective Day Programs at this time.

During the course of the investigation, LPA conducted interviews with staff and reviewed client records, including but not limited to IPP, admission agreements and emergency contact information for all clients.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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-20220209101935
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: 01/27/2023
NARRATIVE
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It was alleged that resident’s hygiene is not being met. Based on interviews and the information that was gathered throughout the course of this investigation, this facility was deficient as evidenced that the restroom that was present in R1’s bedroom was locked and made inaccessible to Resident 1 (R1). It was learned that R1 was an individual who would constantly take showers in order to cope with any behaviors and would take several showers a day. It was learned that the facility management decided to not allow R1 to do so and did not make this coping behavior available to R1 any longer. As a result, R1’s hygiene care needs started to decline, and facility staff were reluctant to deal with R1’s behaviors as they started to increase in frequency. It was learned that facility staff were unable to properly deal with R1’s behaviors and felt that it was just easier to leave R1 alone and not deal with R1 if R1 refused to shower or conduct any of R1’s activities of daily living. Based on the information provided through interview, the facility did not meet the resident’s hygiene needs, therefore this allegation was SUBSTANTIATED.

It was alleged that the facility is in disrepair. Based on interviews and the information that was gathered throughout the course of this investigation, this facility was deficient as evidenced that the restroom that was present in R1’s bedroom had dried urine stains on the restroom floor, as well as urine stains on the walls surrounding the toilet. It was observed that the restroom tile floor was starting to become uneven due to the excessive moisture that was present and needed to be repaired/replaced. In addition, it was observed that the walls surrounding the toilet needed to be replaced/repaired due to the excessive urine stains. Based on observation and information gathered through interviews, the facility was in disrepair, therefore this allegation was SUBSTANTIATED. This allegation was previously investigated and cite on XXXX, therefore no deficiency for this finding will be issued on this day.

It was alleged that the facility was malodorous. Based on interviews and the information that was gathered throughout the course of this investigation, this facility was deficient as evidenced that the restroom that was present in R1’s bedroom contained dried urine stains on the restroom floor with additional urine stains on the walls surrounding the toilet. There was the presence of a strong urine odor upon entry into this restroom. Based on observation and information gathered through interviews, the facility was malodorous, therefore this allegation was SUBSTANTIATED

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative and a copy of this report was provided along with appeal rights.

The Facility Designated Administrator asked for all documentation to this visit to be sent to his email and did not sign any paperwork during the time of visit

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

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220209101935
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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2023
Section Cited
CCR
85088(c)
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85088 Fixtures, Furniture, Equipment and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
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Facility Administrator stated that a review of the section, 85088(c), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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was deficient as evidenced that the restroom that was present in R1’s bedroom was locked and made inaccessible to R1. It was learned that R1 was an individual who would constantly take showers in order to cope with any behaviors and would take several showers a day. It was learned that the facility management decided to not allow R1 to do so and did not make this coping behavior available to R1 any longer. As a result, R1’s hygiene care needs started to decline and facility staff were reluctant to deal with R1’s behaviors as they started to increase in frequency. It was learned that facility staff were unable to properly deal with R1’s behaviors and felt that it was just easier to leave R1 alone and not deal with R1 if R1 refused to shower or conduct any of R1’s activities of daily living. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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Type A
01/28/2023
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(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.
Based on interviews and the information that was gathered throughout the course of this investigation, this facility was deficient as evidenced that the restroom that was present in R1’s bedroom had dried urine stains on the restroom floor, as well as urine stains on the walls surrounding the toilet.
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Facility Administrator stated that a review of the section,80087(a), will be conducted. A statement of correction and set cleaning schedule will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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It was observed that the restroom tile floor was starting to become uneven due to the excessive moisture that was present and needed to be repaired/replaced. In addition, it was observed that the walls surrounding the toilet needed to be replaced/repaired due to the excessive urine stains. This posed an immediate threat to the Health, Safety, and Personal Rights of 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220209101935
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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2023
Section Cited
CCR
80077.4(b)(4)
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80077.4 Care for Clients with Incontinence
(b) If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following:
(4) Ensuring that clients with incontinence are kept clean and dry, and that the facility remains free of odors.
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Facility Administrator stated that a review of the section, 80077.4(b)(4), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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Based on interviews and the information that was gathered throughout the course of this investigation, this facility was deficient as evidenced that the restroom that was present in R1’s bedroom contained dried urine stains on the restroom floor with additional urine stains on the walls surrounding the toilet. There was the presence of a strong urine odor upon entry into this restroom. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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Information submitted must include attendees, trainers, and information discussed.
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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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4