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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 08/24/2023
Date Signed: 08/27/2023 02:21:53 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
05/10/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220510081922
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:
08/24/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Norma BorgesTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility retaliated against family member for filing complaints
INVESTIGATION FINDINGS:
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On 08/24/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Norma Borges, and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings for the allegation above. There was one other staff member present at the time of this visit, Alma Moyamoy.

Current census was 4. A tour of the facility was conducted. A brief interview with FDA Borges was conducted.

Allegation: Facility retaliated against family member for filing complaints
It was alleged that the facility retaliated against family member for filing complaints. During the course of this investigation, LPA conducted interviews and reviewed facility files. Based on interviews that were conducted, it was learned that the facility had concerns regarding R1’s safety due to their responsibility party’s inappropriate actions and behaviors. R1’s responsible party was given a verbal warning by the facility that they were to cease all inappropriate actions and behaviors, or further action would be taken to serve R1 a 30-day notice.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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-20220510081922
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: 08/24/2023
NARRATIVE
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As a result, R1’s placement was in jeopardy due to the inappropriate actions of their responsible party. After a verbal warning was served, the facility filed a Temporary Restraining Order against R1’s responsible party.

Based on the information gathered, the Licensee did not follow Title 22 regulations as this facility was deficient as evidenced by it was learned that the Licensee acted on a punitive nature against R1 due to their responsible party’s inappropriate actions and behaviors. This poses an immediate threat to the Health, Safety, and Personal Rights of the residents in care.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Exit interview was conducted with Facility Designated Administrator (FDA), Norma Borges and a copy of this report was provided along with confidential names list and appeal rights.

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

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220510081922
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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
80072(a)(3)
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(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 is not met as evidenced by:
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Licensee shall read regulation 80072(a)(3) and submit a signed declaration of understanding to LPA by the POC due date.
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Based on interviews, the Licensee did not comply with the section above by not ensuring that R1 was free of corporal punishment and threat. It was learned during the course of the investigation that the Licensee verbally warned R1’s responsible party that if they did not cease their actions that R1 would be provided a 30-day notice. This poses an immediate Health, Safety and Personal Rights risk to the residents 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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3