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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 10:20:43 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
10/26/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221026113035
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:
11:30 AM
MET WITH:Andrea RushTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff do not treat with residents with dignity
Staff encouraged resident in care to self-harm.
Staff did not allow resident to leave their room while in care.
Staff are not reporting incidents involving residents in care.
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 Rush contact 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.
Allegation: Staff do not treat residents with dignity
It was alleged that staff speak inappropriately to the residents in care. During the course of the investigation, LPA conducted 4 staff and 4 resident interviews. 4 out 4 staff members disclosed that a former employee would treat a resident in an inappropriate manner by teasing them about their behavior, make negative comments on the residents appearance and how much the resident ate.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
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 8
Control Number 27-AS-20221026113035
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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1 out 4 residents stated that they have witnessed a staff member tease another resident and allow them to run around with no clothes on. It was also stated that the staff member would comment on the resident's appearance and tease them about the way they ate. 2 out 4 residents stated that they were treated with dignity and respect from other staff members. 2 out 4 residents were unable to complete interviews due to medical conditions. Based on interviews and the information gathered the staff did not treat the residents with dignity.
As a result of this investigation, this department 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.

Allegation: Staff encouraged residents in care to self-harm
It was alleged that staff encouraged resident in care to self-harm. During the course of the investigation, LPA conducted 4 staff and 4 resident interviews and reviewed facility records. 2 out 4 staff interviews stated that they have witnessed a former staff member (S1) encourage a resident to self harm. Based on facility records, R1's current IPP states that R1 is non-veral and has a history of self-harming behaviors when frustrated. It was witnessed by staff that S1 would encourage R1 to continue to hurt themselves because they have are not hurting anyone else. 4 out 4 staff members denied that they have encourage residents to self harm. 2 out 4 staff members denied that they have seen any other staff members encourage residents in care to self-harm. 2 out 4 residents stated denied that any staff members encouraged them to hurt themselves. 2 out 4 residents denied witnessing any staff members encouraging other resident's to self harm.2 out 4 residents were unable to complete interviews due to medical conditions. Based on interviews and the information gathered staff did encourage residents in care to self-harm.

As a result of this investigation, this department 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.


Allegation: Staff did not allow resident to leave their room while in care.

It was alleged that staff did not allow resident to leave their room while in care. During the course of the investigation, LPA conducted 4 staff and 4 resident interviews. 4 out 4 staff members denied any residents in their room. 4 out 4 staff members denied that they have seen any other staff members lock any residents in their room. 1 out 4 residents stated that S1 would lock the room when they were having a behavior to teach them a lesson.

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

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20221026113035
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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1 out 4 residents stated that they were not allowed to leave the room and had to break the lock in order to leave. 1 out 4 residents stated that they have seen S1 also lock another resident in their rooms because they were exhibiting behaviors. 1 of 4 residents denied that they not allowed to leave their room. 2 out 4 residents were unable to complete interviews due to medical conditions. Based on interviews and the information gathered, staff did not allow residents to leave their room while in care.

As a result of this investigation, this department 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. This allegation is substantiated however no licensing citation will be given for this allegation. This allegation was cited on a complaint report on 01/27/2023.

Allegation: Staff are not reporting incidents involving residents in care

It was alleged that staff are not reporting incidents involving residents in care. During the course of the investigation, LPA conducted staff interviews. In addition, LPA reviewed facility records. Based on interviews conducted it was learned that several incidents between two residents occurred throughout the month of October 2022. It was learned during the interviews that R1 and R2 were roommates in a shared bedroom at the facility who have been consistently fighting on a daily basis. 1 out 4 staff members stated that during their shift one day walked in on R2 choking R3 in their bedroom. It was stated by staff that they reported the incident to the Facility House Manager and the Facility Designated Administrator. 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 reviewed facility records and faxes that have been received by the department.Based on records reviewed the above incident was not reported to the department, the last incident that was reported to the department via Fax was on 07/25/2022.

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.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. 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: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20221026113035
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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by: Based on interviews conducted, the facility did not ensure that R1 was not accorded with dignity.
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S1 no longer works and is associated with the facility. Facility Administrator stated that a review of the section, 80072(a)(1), 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
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S1 did not accord the resident with dignity by teasing them about their behavior, make negative comments on the residents appearance and how much the resident ate. This poses an immediate health, safety, and personal rights risk to persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 06/02/2023 COB. Information submitted must include attendees, trainers, and information discussed.
Type A
06/02/2023
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(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. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not ensure the resident was free of punishment.
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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
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The facility did not ensure that S1 used mitigating interventions to stop R1 from their self-harming behaviors. S1 encouraged R1 to continue to harm themself.
This poses an immediate health, safety, and personal rights risk to persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 06/02/2023 COB. Information submitted must include attendees, trainers, and information discussed.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20221026113035
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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
80061(c)
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(c) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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 Facility Administrator stated that a review of the section, 80072(a)(1), 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
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This is not met as evidenced by: Based on on interviews and records review the facility did not ensure that the incident between R2 and R3 was reported to CCL in a timely manner. R2 was found choking R3 during a staff members shift. This poses an immediate health, safety, and personal rights risk to persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 06/02/2023 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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
10/26/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221026113035

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:
11:30 AM
MET WITH:Julian HawesTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff speak inappripriately to resident(s) in care
Staff scream at resident in care.
Staff do not ensure that facility has a sufficient amount of food for residents in care.
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. JLPAs asked that SM Hull contact 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.
Allegation: Staff speak inappropriately to residents in care.
It was alleged that staff speak inappropriately to residents in care. During the course of this investigation, the LPA conducted 4 staff and 4 resident interviews. 4 staff interviews were conducted. 4 out of 4 staff members denied that they speak inappropriately to the residents in care. 4 out of 4 staff members stated that they have not heard any other staff members speak inappropriately to residents in care. 2 out 4 staff members stated that they do not believe that other staff members speak inapproriately but may show other actions against the residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20221026113035
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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2 out 4 residents denied that any staff speak inappropriately to them. 2 out 4 residents denied hearing any inappropriately comments towards other residents. 2 out 4 residents were unable to complete interviews because of medical reasons. Based on interviews conducted, it was unclear if staff spoke inappropriately to residents in care.
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.

Allegation: Staff scream at resident in care.


It was alleged that staff scream at residents in care. During the course of this investigation, the LPA conducted 4 staff and 4 resident interviews. 4 staff interviews were conducted. 4 out of 4 staff denied that they scream at any residents in care. 4 out of 4 staff members denied hearing any other staff members screaming at residents in care. 2 out 4 residents denied that any staff scream at them. 2 out 4 residents denied that they have witnessed any staff members scream other residents in care. 2 out 4 residents were unable to complete interviews because of medical reasons. Based on the interviews conducted, it was unclear if staff scream at the residents in care.
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.

Allegation: Staff do not ensure that facility has a sufficient amount of food for residents in care


It was alleged that staff do not ensure that facility has a sufficient amount of food for residents in care. During the course of this investigation, the LPA toured facility and conducted staff and resident interviews. Based on observation, the LPA toured the facility to ensure that there was a sufficient amount of food available based on Title 22 regulations. LPA observed that there was a sufficient amount of 2 day perishable food supply and 7 day non-perishable food supply for the amount of residents during the visits conducted on 11/03/2022 and 12/01/2022. An interview 4 staff members were conducted. 4 out of 4 staff members stated that the facility does weekly grocery trips in order to supplement perishable food supply and bi-weekly grocery trips are conducted to supplyment non-perishable food supply. 4 out of 4 resident interviews were conducted. 2 out 4 residents stated that the facility always has food and enjoy the food available to them. 2 out 4 residents were unable to finish interviews due to medical conditions. Based on interviews and LPA observation, it was unclear if the staff do not ensure that the facility has a sufficient amount of food for residents in care.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20221026113035
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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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.

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 via email. An electronic email read receipt confirms receiving these documents.

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

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8