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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 06:28:47 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
08/01/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220801120753
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:
02:00 PM
MET WITH:Julian HawesTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff locked a client in a room while in care
INVESTIGATION FINDINGS:
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On 1/27/2023 at 2:00pm, 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 program at this time.

During the course of the investigation, LPA conducted interviews and reviewed facility files including but not limited to, physicians reports, ID and Emergency Contact Information, and incident reports regarding this complaint.
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 5
Control Number 27-AS-20220801120753
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 staff locked a client in a room while in care. Based on interviews and information gathered it was learned that R1 was upset after a phone call with their loved one and began to become aggressive toward staff. R1 went to the front of the facility where they took rocks from the facility driveway and began throwing them at the cars parked near by. Staff repeatedly asked R1 to stop and to come inside. After several minutes, R1 came inside and went straight into their room. It was denied by the staff that they locked the resident inside the room an interview with R1 was conducted. R1 confirmed that after they were throwing rocks at the cars outside they went into their room. It was stated by R1 that one staff member came over to their room and locked the door from the outside which did not allow for R1 to leave their room. R1 stated that it was stated by the staff member that they were locked in their room because their behavior was not acceptable. R1 asked to leave the room but staff did not allow them to leave. Based on the information gathered, it is clear that the staff locked a client in a room while in care.

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 5
Control Number 27-AS-20220801120753
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
80072(a)(3)
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Personal Rights 80072(a)(3)
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Facility Administrator stated that a review of the section, 80072(a)(3), 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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This requirement is not met as evidenced by: Based on interviews and the information that was gather throughout the course of this investigation, the Licensee did not ensure that the personal rights of the residents were guaranteed by the staff members present at the facility. It was learned that while a resident was upset and presenting behavior in their room, the staff member punished the resident by locking them in their room for a period of time as a form of punishment. This poses an immediate threat to the Health, Safety, and Personal Rights risk to the residents in care.
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by the due date of 1/28/2023 COB. 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: 3 of 5
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
08/01/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220801120753

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:
02:00 PM
MET WITH:Julian HawesTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Staff hit a client with an object while in care
INVESTIGATION FINDINGS:
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On 1/27/2023 at 2:00pm, 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 program at this time.

It was alleged that staff hit a client with an object while in care. Based on interviews conducted it was learned that R1 was upset after a phone call with their loved one and began to be aggressive towards staff. After staff repeatedly asked R1 to calm down, staff was unable to calm R1 down. R1 proceeded to go outside of the facility where staff observed R1 grab rocks from the facility driveway to throw at the cars parked around the facility. Staff asked R1 to stop and it was stated that staff was then hit by a rock.
Unsubstantiated
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: 4 of 5
Control Number 27-AS-20220801120753
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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Staff denied hitting the client with an object. An interview with the resident was conducted, and it was confirmed by the resident that they were upset because due to a phone call that took place earlier in the day. R1 stated that they went outside to cool off but began throwing rocks at everything that the came across. R1 denied that they were hit at any time during this incident. Based on the interviews conducted and information gathered it was unclear if the staff hit a client with an object while in care.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.


There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the Facility Designated Administrator,Julian Hawes.

At this time the Facility Designated Administrator asked for all documentation to this visit to be sent to his email and did not sign any paperwork at the times of the 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: 5 of 5