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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 07/07/2023
Date Signed: 07/14/2023 02:39:44 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:
07/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea Rush TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff failed to provide appropriate transportation for resident in care
INVESTIGATION FINDINGS:
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On 07/07/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Kesha Lewis 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 SM Rush to call the Facility Designated Administrator (FDA), Julian Hawes, to inform him that Community Care Licensing (CCL) was present at the facility. LPAs were informed that FDA Hawes was unable to come to the facility at this time. LPAs continued the visit with SM Rush. There was one other staff member present at the time of the visit, Alma Moyamoy. The current census was 4. 1 out 4 residents were out at their respective day program.

The purpose of this visit is to deliver complaint findings for the allegation above.

It was alleged that staff failed to provide appropriate transportation for resident in care. Throughout the course of the investigation, LPA Pascua reviewed facility files and conducted interviews.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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-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: 07/07/2023
NARRATIVE
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Title 22 regulations state, “Arrangements for clients to attend available community programs, when clients have needs, identified in the needs and services plan, which cannot be met by the facility but can be met by community programs. Based on the interviews conducted it was learned that on 03/28/2023 the facility van was in a fender bender accident and was unable to transport residents to and from their respective activities for several days. The facilities plan of operation states that the facility will provide or have provisions for residents medical and dental appointments, community activities, emergencies, and to and from school or day programs. A review of Resident 2‘s (R2) Individual Program Plan (IPP) was conducted. R2’s IPP states that the resident would be transported by the facility to school daily. Based on the interviewed conducted it was learned that R2 would be indecisive or would not be ready to go to school on time. Once the resident was not ready at a certain time, the facility would not take them to school. In addition, when R2 would be dropped off early at the school or would be picked up later than scheduled pick up. Many times the school would have to wait for R2 to get picked up almost an hour after pick up time. Based on the information gathered, the staff did not to provide appropriate transportation for resident in care.
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 the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the Facility Designated Administrator,Julian Hawes and staff member, Andrea Rush via email. An electronic email read receipt confirms receiving these documents.

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

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
85064(6)
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Administrator Qualifications and Duties
(6) Arrangement for the clients to attend available community programs, when clients have needs, identified in the needs and services plan, which cannot be met by the facility but can be met by community programs.
This is not met as evidenced by:
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The facility states that a review of the section 85064(6) will be conducted. In addition, a statement of correction that highlights a plan to ensure that all transportation needs are met for residents at the facility will be sent to the LPA’s
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Based on record review and interviews conducted, the Licensee did not ensure that R2 had proper transportation to and from school and did not ensure that further arrangements were made after transportation was no longer available by the facility. The facility van was not available for several days due to a fender bender accident that occurred on 03/28/2023 with residents in care. This poses a potential health, safety, and personal rights risks to persons in care.
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email at Arielle.pascua@dss.ca.gov by the POC date 07/28/2023.
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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: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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
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:
07/07/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea Rush TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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2
3
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9
Lack of supervision resulting in resident engaging in a physical altercation with another resident.
INVESTIGATION FINDINGS:
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On 07/07/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Ruth Wallace 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 SM Rush to call the Facility Designated Administrator (FDA), Julian Hawes, to inform him that Community Care Licensing (CCL) was present at the facility. LPAs were informed that FDA Hawes was unable to come to the facility at this time. LPAs continued the visit with SM Rush. There was one other staff member present at this time, Alma Moyamoy. The current census was 4. 1 out 4 residents were out at their respective day program.

The purpose of this visit is to deliver complaint findings for the allegation above.

It was alleged that there was a lack of supervision resulting in resident engaging in a physical altercation with another resident. Throughout the investigation, LPA Pascua reviewed facility files and conducted interviews.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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-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: 07/07/2023
NARRATIVE
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Based on interviews conducted it was learned that Resident 1 (R1) was frustrated and became verbally aggressive with a staff member. R1 began to approach the staff member when Resident 2 (R2) interjected themself to protect the staff member. R2 began to speak with R1 asking them to stop. R1 continued the behaviors and R2 began to antagonize R1 by speaking to them in a derogatory manner. Staff tried to stop the incident by speaking with R1 to calm down. R1 approached R2 and punched them in the face. R2 pushed back as a reaction causing R1 to fall back and hit their hit on the wall. R1 was shown to have a large bruise on their forehead after the altercation. A reviews of R1 and R2’s Individual Program Plan (IPP) was conducted. Based on R1’s IPP, it states that R1 may display disruptive behavior such as aggression and emotional outbursts. R1 is also known to curse and use racial slurs with both staff and those in the community. Based on R2’s IPP, it states that R2 has a mood disorder that causes episodic behaviors due to their environment or being frustrated. Based on prior incidents, R1 and R2 were former roommates and are known to physically and verbally fight with each other. Based on the information gathered throughout the investigation, it is unclear that there was a lack of supervision resulting in resident engaging in a physical altercation with another resident.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.



An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the Facility Designated Administrator,Julian Hawes and staff member, Andrea Rush via email. An electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5