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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 06/26/2023
Date Signed: 07/14/2023 10:02:43 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
02/23/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230223083540
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:
06/26/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea RushTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived to this facility unannounced to conduct a complaint visit. LPAs were greeted by Staff Member (SM), Andrea Rush and explained the purpose of the visit. LPA Pascua asked that SM Rush contact the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. It was learned that FDA, Julian Hawes, was unable to come to the facility due to other meetings. LPAs continued the visit with SM Rush. The purpose of the visit was to deliver complaint findings for the allegation above.

Allegation: Personal Rights
Throughout the investigation it was learned that Resident 1(R1) and Resident 2 (R2) were residing in a shared bedroom at the facility. Often times, R1 and R2 would get into verbal arguments that would lead into physical altercations. Based on interviews conducted, on 02/21/2023, R1 and R2 were in a physical altercation in which staff attempted to break up. As a result of the incident, it was decided by the facility that it would be best that R1 slept on the couch. It was stated by staff that, R1 chose to sleep on the couch as a result of the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
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-20230223083540
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: 06/26/2023
NARRATIVE
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LPA conducted several other interviews that confirmed that R1 did not chose to sleep on the couch. It was learned through these interviews that R1 was the only resident to sleep on the couch and felt as they was being punished by the facility. In addition, it was reported that R1 was sleeping on the couch for two consecutive days.

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 immediate civil penalty in the amount of $250 was assessed for violations of Sections 80072(a)(3). This civil penalty was due to a repeat violation. This facility was cited for this violation on 06/01/2023. The Facility Designated Administrator was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.

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: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230223083540
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: 06/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2023
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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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 06/27/2023 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: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
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
02/23/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230223083540

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:
06/26/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea Rush TIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
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7
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9
Illegal Eviction
INVESTIGATION FINDINGS:
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On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived to this facility unannounced to conduct a complaint visit. LPAs were greeted by Staff Member (SM), Andrea Rush and explained the purpose of the visit. LPA Pascua asked that SM Rush contact the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. It was learned that FDA, Julian Hawes, was unable to come to the facility due to other meetings. LPAs continued the visit with SM Rush. The purpose of the visit was to deliver complaint findings for the allegation above.

It was alleged that there was an illegal eviction. Throughout the investigation LPA conducted several interviews and reviewed facility files. It was learned through interviews conducted that Resident 1’s (R1) Service Coordinator (SC) recieved an email from the Licensee on 02/09/2023 stating that the facility would like to provide a 30-day notice. SC confirmed that a verbal notice was provided but did not recieve a formal written notice. It was reported that the the Regional Center was in process of searching for new placement due to previous incidents prior to the 30-day notice.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
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-20230223083540
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: 06/26/2023
NARRATIVE
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Based on an interview with an outside party, it was learned that the Regional Center was in the process of searching for a new placement due to the 30-day notice. It is unclear at this time if this was an illegal eviction.
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: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5