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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 02:35:58 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
04/04/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230404121145
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:
12:00 PM
MET WITH:Andrea Rush TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff failed to meet reporting requirements
Staff failed to provide resident’s authorized representative with an incident report
INVESTIGATION FINDINGS:
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On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived 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 call the Facility Designated Administrator (FDA) and inform them that CCL was present at this time. LPA Pascua learned that FDA, Julian Hawes, was unable to make it to the facility at this time. LPAs continued the visit with SM Rush. The purpose of this visit was to deliver complaint findings for the allegations above.

Allegation: Staff failed to meet reporting requirements
It was alleged that staff failed to meet reporting requirements. Throughout the course of this investigation LPA conducted interviewed and reviewed facility files. Based on interviews conducted, it was learned that Resident 1 (R1) became aggressive with staff and Resident 2 (R2) decided to interject themself between R1 and staff. R2 reportedly antagonized R1 which lead for R1 to punch R2 with a closed fist to R2’s chest.

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 3
Control Number 27-AS-20230404121145
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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R2 responded by punching R1 back which lead for R1 to fall back and hit their head on an object. An interview with the Regional Center was conducted which confirmed this incident happening on 04/04/2023 LPA reviewed facility records of incident reports regarding R1 and R2 but was unable to obtain an incident report regarding any incidents between R1 and R2. 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 SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

Allegation: Staff failed to provide resident’s authorized representative with an incident report.

It was alleged that staff failed to provide resident’s authorized representative with an incident report. Throughout the course of this investigation LPA conducted several interviews and reviewed facility records. Based on interviews conducted it was learned that R1 and R2 have been in several verbal and physical altercations throughout the months of November 2022-April 2023. It was reported that several verbal and physical altercations have not been reported to the regional center and their responsible parties. Interviewed conducted also revealed that the regional center and responsible parties would know of incidents through the residents who reside at the facility. LPA reviewed facility records and was unable to obtain multiple incident report regarding R1 and R2.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED 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 80061(c). 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.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulation

An exit interview was conducted, a copy of the this reported 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 3
Control Number 27-AS-20230404121145
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
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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A civil penalty for $250 was assessed today for a repeat violation.
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 R1 and R2 was reported to CCL in a timely manner. R2 punched R1 resulting R1 to fall back and hit their head on an object. 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.
Type A
06/27/2023
Section Cited
CCR
80061(f)
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(f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
This is not met as evidenced by: Based on interviews and records review the facility did not ensure that the incident between R1 an R2 was reported to their authorized representative.
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Facility Administrator stated that a review of the section, 80072(f), 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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arielle.pascua@dss.ca.gov. by the due date of 06/27/2023 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: 06/26/2023
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)
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