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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 07/07/2023
Date Signed: 07/19/2023 01:39:42 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
04/11/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230411123659
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:
11:00 AM
MET WITH:Andrea Rush TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication
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. 3 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 mismanaged resident’s medication. Throughout the investigation LPA conducted interviews and reviewed facility documents. Based on interviews conducted it was learned that R1 had several incidents regarding medication.
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 3
Control Number 27-AS-20230411123659
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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On three separate occasions, R1 left the facility for a home visit. During the first home visit it was observed by the family member that the resident did not have their own medication box but was provided another resident’s. The family called the facility and it was confirmed by the house manager that the medication box was in fact for another resident. During the second visit, it was observed that two of the resident’s medication only had one dose of medication left and did not have the refills. The family contacted the facility to inform them that there was only one medication left and asked if there was another refill available. The house manager notified the family member that they forgot to provide the family with the refill and would come meet the family halfway to provide the medication. R1 went on a third home visit, and it was learned that when administering night medication, it was observed that an AM medication that was packaged separately was not provided. The family did have extra medication to ensure that the resident had their PM Medication as prescribed by the physician. The family contacted the facility where it was learned that staff informed the family that the facility did not have any more refills for that medication at the time. Furthermore, it was learned through interview that staff informed the family and the service coordinator that the reason that there was no medication given was due to not having refills available and was currently working with the family to obtain a renewal. R1’s Medication Administration Record and Medication were reviewed. Based on observation, it was found that the medication for Vyvanse was refilled on a later date from 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 immediate civil penalty for $250 is being assessed for the violation of 80075(b). This facility was cited for this violation from a prior visit on 06/02/2023.

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 3
Control Number 27-AS-20230411123659
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 A
07/10/2023
Section Cited
CCR
80075(b)
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80075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This is not met as evidenced by: The facility did not ensure that the resident was assisted with their prescription medication.
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The facility states that a review of the section 80075(b) will be conducted. In addition, a statement of correction that highlights a policy and procedure on how medication management will be processed on a daily basis.
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. Based on interview, the facility did not provide the resident with the correct amount of medication during their outings while out of the facility. This causes an immediate risk to health, safety, personal rights risk to the persons in care.
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 Facility shall conduct medication training to include in-service training to remind staff of medication procedures and documentation. 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 Arielle.pascua@dss.ca.gov by the due date 07/10/2023.
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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 3