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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 06/02/2023
Date Signed: 06/14/2023 12:01:09 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
01/20/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230120163415
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:
06/02/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andrea Rush TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility heater is in disrepair
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. SM Rush was unable to contact FDA Julian Hawes via telephone. LPA proceeded the visit with SM Rush.
Current census was 4.There was one other staff member present, Alma Moyamoy. The purpose of this visit was to delivery complaint findings for the allegations above.
Allegation: Facility heater is in disrepair
It was learned that the facility heater is in disrepair. An interview was conducted with 4 staff members and 3 residents. 4 of out 4 staff members stated that the facility heater has not been working during the cold months through the month of December. 4 out 4 staff members stated that there has been companies out to fix the heater but it was not fixed. 4 out 4 staff members state that there are electric heaters throughout the facility to heat up the facility while the heater is under maintenence. An interview with 3 residents were conducted. 2 out of 3 residents stated that they have seen an individual work on the facility heater but were unsure if it was working.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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 7
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
01/20/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230120163415

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:
06/02/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andrea Rush TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not administering medication as prescribed
Facility is not keeping an adequate medication record for residents
Facility does not provide activities to residents
Facility does not have a sufficient amout of food
Facility does not have sufficient amount of staff to meet resident needs
Facility does not provide a safe environment for residents
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. SM Rush was unable to contact FDA Julian Hawes via telephone. LPA proceeded the visit with SM Rush.
Current census was 4.There was one other staff member present, Alma Moyamoy.
Allegation: Facility is not administering medication as prescribed
It was alleged that the facility is not administering medication as prescribed. Throughout the investigation LPA conducted interviews and reviewed facility documents.
Based on interviews conducted it was learned that R1 had several incidents regarding medication. On 10/22/2022, R1 left the facility for a home visit. During the home visit it was found that the family was provided another resident's medication box. The facility was called and it was confirmed by the house manager that the medication was in fact for another resident.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20230120163415
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: 06/02/2023
NARRATIVE
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On 11/23/2023, R1 ft the facility a second time for a home visit. When it was time to administer night medication, it was observed that two medications had only one medication left in each box and did not have the refills. The family contacted the facility to inform them that there was only one medication left and asked if another refill was available. The house manager confirmed that they did not provide the family with the refills and would come meet the family half way to provide the medication. On 04/09/2023, R1 left the facility for a 3rd home visit. When administering night medications, it was observed that an AM medication that was packaged separately was not provided. During the home visit, the family did have extra medication to ensure that the resident had their PM medication as prescribed by the physician. It is unclear that the facility did not ensure that medication was not administering medication as prescribed.
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: Facility is not keeping an adequate medication record for residents
It was alleged that the facility is not keeping an adequate medication record. Based on interviews, records review, and observation it was determined that the resident's medication reflected what was given based on the medication dispensing logs. LPA observed medications stored at the facility to match physicians orders and medication records. LPA Pascua interviewed 4 staff members, 4 out of 4 staff members stated that medication is given per doctors orders. 4 out of 4 staff members also state that medication logs are audited by the Administrator on daily basis to ensure that medication will match with the count of medication available. 4 out of 4 staff membered both reported that they watch residents to ensure that their medication was taken. Record review revealed that medications are documented appropriately to indicate when medication is taken or refused. it is unclear if the facility is not keeping an adequate medication record for residents.
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: Facility does not provide activities to residents


It was alleged that the facility does not provide activities to residents. Throughout this the investigation LPA conducted 4 staff interviews and 4 resident interviews and reviewed facility records. 4 out of 4 staff members state that most of the residents go out to day program during the day.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20230120163415
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: 06/02/2023
NARRATIVE
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4 out 4 staff members state that when the resident's come home from day program they request to rest and have dinner will stay in their rooms. 4 out 4 staff members stated that they will take residents to the park or any other outings that they request during the week. 2 out 4 residents state that they have activities throughout the week that they can work on. 2 out of 4 residents state they also go out to the mall or any other places that they request during the week. 2 out 4 residents state they they also enjoy being at home and watching tv or playing games as an activity. 2 out 4 residents were unable to complete interviews due to their medical conditions. It was unclear if the facility does not provide activities to residents.
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: Facility does not have a sufficient amount of food


It was alleged that staff do not ensure that facility has a sufficient amount of food. 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..

Allegation: Facility does not have sufficient amount of staff to meet resident needs
It was alleged that staff do not have sufficient amount of staff to meet resident needs. During the course of this investigation LPA conducted 4 staff interviews and 4 resident interviews. 4 out 4 staff members state that they believe that having an extra person on the shift would help but are able to meet the residents needs at this time. 2 out 4 residents reported being satisfied with the care they are receiving with no issues with any staff members. 2 out 4 residents report that they believe that all their needs are being met with the staff they currently have at the facility. In addition, LPA observed 2 staff members for 2 residents during facility visits on, 12/15/2022, 12/27/2022, and 1/17/2023. Based on interviews and observation it is unclear if the facility has a sufficient amount of staff to meet resident needs.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20230120163415
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: 06/02/2023
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.

Allegation: Facility does not provide a safe environment for residents

It was alleged that staff do not provide a safe environment for residents. During the course of this investigation LPA conducted 4 staff interviews and 4 resident interviews. 4 out 4 staff members state that they believe that their main proirity is to keep the residents safe and are able to keep them safe at this time. 2 out 4 residents reported that they feel safe that the facility. Based on interviews and observation it is unclear if the facility does not provide a safe environment for residents. 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.



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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20230120163415
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: 06/02/2023
NARRATIVE
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2 out 3 residents stated that there are heaters around the facility and were comfortable with the temperature. In addition, a separate complaint visit on 12/01/2023 by LPA Pascua and LPM Richardson was conducted. It was observed that there were several white heaters placed throughout the facility. LPA Pascua and LPM Richardson learned that the facility heater was in disrepair during this time of the visit.

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.

An exit interview was conducted, a copy of this report 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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20230120163415
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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
80087(a)
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(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. This was not met as evidenced by: Based on interview and observation, the facility did not ensure that the facility heater was not in working condition.
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The facility to send a plan to CCL on how the facility heater will be fixed. A copy of services rendered will be provided to the LPAs email at arielle.pascua@dss.ca.gov by the POC date 06/30/2023.
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This is a potential health, safety, and personal rights risk to persons 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: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7