502700754-11-28-2023-27-AS-LRIS-CY324G-20231129160353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700754
Report Date: 11/16/2023
Date Signed: 11/28/2023 10:29:24 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2023 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230821091016

FACILITY NAME:	DREAM CARE		FACILITY NUMBER:	502700754
ADMINISTRATOR:	NORMA BORGES		FACILITY TYPE:	735
ADDRESS:	2004 KRUGER DRIVE		TELEPHONE:	(209) 661-4666
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	4	CENSUS: 3	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Andrea Rush		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff physically abused resident
Staff Threatened Resident
Staff does not treat resident with dignity

INVESTIGATION FINDINGS:

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On 11/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with House Manager (HM), Andrea Rush and explained the purpose of the visit. LPA asked that HM Rush call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. It was learned that the FDA was out on vacation at this time. There was one other staff member present, Benjamin Nutall. The purpose of this visit was to deliver complaint findings for the allegations above.
Current Census was 3. 1 out 3 residents were out at their respective day programs at this time. A tour of the facility was conducted. A brief interview with FDA Borges was conducted.

Allegation: Staff physically abused resident
It was alleged that staff physically abused resident. During the course of this investigation LPA conducted staff and resident interviews. It was learned through these interviews that S1 was preparing breakfast with S2 while the resident's got ready to go out to their respective day programs. It was at this time where R1 started to state inappropriate words out loud to S1 and S2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230821091016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE	FACILITY NUMBER: 502700754
	VISIT DATE: 11/16/2023

NARRATIVE

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S1 repeatedly asked R1 to stop ask what they were saying was inappropriate. R1 continued to state inappropriate words and S1 was upset and went into the laundry room. S2 then asked R1 to stop what they were saying. It stated that S2 then took a pillow and forcefully put it towards R1's face. However, this was denied by S2 and stated that they did not touch R1 and only warned them to stop. An interview with 2 other staff members were conducted. 2 out 2 staff members stated that they were not at the facility at the time of the incident. 2 out 2 staff membered denied ever witnessing another staff member physically abusing a resident. An interview with one other resident was conducted where it was denied that they witnessed another resident being physically abused. 2 out 2 residents could not be interviewed due to their medical condition. Based on the information gathered, it is unclear that the staff member physically abused the resident.

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

Allegation: Staff Threatened Resident

It was alleged that the staff threatened a resident. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted it was learned that R1 speaking to S1 and S2 in an appropriate manner. S1 and S2 repeatedly asked for R1 to stop speaking inappropriately, however, R1 did not stop. R1 admitted that they were speaking inappropriately and did not stop when asked. S2 denied ever threatening the resident but only asked that they stopped speaking inappropriately. Based on the information gathered, it is unclear that the staff member threatened the resident. An interview with 2 other staff members were conducted. 2 out of 2 staff members denied ever threatening a resident or hearing another staff member threaten a resident. An interview with 1 other resident was conducted, where it was also denied ever being threatened by staff or heard staff threaten another resident. 2 out 2 residents could not be interviewed due to their medical condition. Based on the information gathered, it was unclear that a staff member threatened a resident.

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230821091016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE	FACILITY NUMBER: 502700754
	VISIT DATE: 11/16/2023

NARRATIVE

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Allegation: Staff does not treat resident with dignity
It was alleged that staff does not treat resident with dignity. It was alleged that staff did not provide resident with dignity. During the course of this investigation, LPA interviewed 4 residents. 1 out of 4 residents stated that they felt that the facility staff did not provide them with dignity. 1 out 4 residents stated that the facility staff did provide them with dignity and allowed them to be independent and respected their personal spaces. 2 out 2 residents could not be interviewed due to their medical condition. An interview with facility staff revealed that the facility has had some issues with R1 but state that they were moving out. Facility staff also denies that they do not provide residents with dignity. Based on the interviews and information gathered it is unclear that the staff did not provide the resident with dignity.

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.

There were no deficiencies observed or cited at this time. An exit interview was conducted. Due to printer issues, a copy of this report was provided via email to the Facility Designated Administrator. A read receipt confirms retrieval of the 9099 and 9099-C.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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