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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 06/01/2023
Date Signed: 06/14/2023 02:38:00 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
12/27/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221227141814
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:
06/01/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andrea RushTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Failure to Report
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a complaint visit. LPAs were greeted by staff member, Andrea Rush and explained the purpose of the visit. LPAs asked that SM Rushcontact the Facility Designated Administrator (FDA) at this time to inform them that CCL was present. LPA Pascua spoke to FDA Julian Hawes and it was learned that he was unable to come to the facility at this time and could continue the visit with SM Andrea Rush.There was one other staff member present at the facility, Alma Moyamoy.The purpose of this visit was to delivery complaint findings for the allegations above.
Current census was 4. A tour of the facility and a brief interview with SM Rush were conducted

It was alleged that the facility fails to report. Based on interviews conducted it was learned that several resident and facility incidents occurred between the months of October to January 2023. On 12/01/2022, a complaint visit from LPA Pascua and Licensing Program Manager (LPM) Stephen Richardson was conducted. It was learned during this visit that the facility heater was under repair because it was not producing heat throughout the facility. LPA Pascua observed several space heaters throughout the facility in order to keep the facility temperature within a reasonable range.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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 2
Control Number 27-AS-20221227141814
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: 06/01/2023
NARRATIVE
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Staff interviews disclosed that R1 has eloped from the facility several times. In November 2022, R3’s debit card was missing and P&I funds for residents was also missing. It was learned that an internal investigation was conducted at the facility and the facility terminated an employee who was responsible for the missing P&I funds. On 1/14/2023, R1 eloped from the facility because they were bored at the facility. The staff attempted to bring R1 back to the facility but was unable to because R1 went on a public bus. It was stated by staff that they notified the Licensee via telephone call and text but was unable to reach contact them. In addition, it was reported by staff that R1 and R2 consistently fight causing physical altercations between each other. It was reported that sometime in October 2022, R1 was found on top of R2 choking them on the neck. It was asked by the staff on shift to stop and was reported to the Licensee and Facility Designated Administrator. 6 out of 6 staff members state that when have an incident occur on their shift they were trained to provide a report to the Facility Designated Administrator or Licensee for review. 6 out of 6 staff members state that once an incident occurs they also provide phone calls to each of the Facility Designated Administrator or Licensee to notify them of what has happened.

An interview with the resident's service coordinator and facility Liaison from Valley Mountain Regional Center was conducted. It was confirmed through these interviews that they were unaware of this incident and was not reported. LPA Pascua also reviewed facility records and faxes that were received by the department. Based on the records reviewed the above incidents were not reported to the department. The last incident report that was received by the department was on 7/25/2022.

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. This allegation is substantiated however no licensing citation will be given for this allegation. This allegation was cited on a complaint report on 06/01/2023.

An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the Facility Designated Administrator,Julian Hawes via email. An electronic email read receipt confirms receiving these documents.

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

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2