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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 02/09/2023
Date Signed: 02/10/2023 08:55:36 AM

Document Has Been Signed on 02/10/2023 08:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
02/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma MoyamoyTIME COMPLETED:
02:00 PM
NARRATIVE
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On 2/09/2023 at 10:00am, Licensing Program Manager (LPM), Stephen Richardson, Licensing Program Analyst (LPA) Arielle Pascua, and Valley Mountain Regional Center Liaison (VMRCL), Jennifer Stone arrived at this facility unannounced to conduct a case management visit. LPM, LPA, AND VMRCL were all greeted by staff member (SM), Alma Moyamoy and explained the purpose of the visit. At this time it was asked for SM Moyamoy to contact the Facility Designated Administrator (FDA), Julian Hawes to inform him that CCL and Valley Mountain Regional Center were at the facility at this time. It was at this time that FDA Hawes notified LPM Richardson that he was out of the facility at this time to drop the resident off at their respective day program. FDA Hawes informed LPM Richardson that he will be arriving back at the facility in 30 minutes. LPM, LPA, AND VMRCL waited 30 minutes for FDA Hawes arrival outside of the facility. At 10:30am, LPM, LPA and VMRCL went back to the facility and asked for SM Moyamoy to call FDA Hawes. FDA Hawes allowed CCL and VMRC to enter the facility while he was not there. Current census was 4.

During this time it was learned that the SM did not have facility files readily available for CCL and VMRC to review because it was stated by SM Moyamoy that she did not have the key to the facility files and medication. At 10:45am, LPM, LPA and VMRCL toured the facility.
At 11:30am, FDA Hawes and SM Iboni James arrived at the facility. A brief interview with FDA Hawes was conducted. CCL and VMRC asked FDA Hawes for facility files and were able to look at facility files at this time. LPA Pascua reviewed facility documents and obtained copies.

Due to the observations made during this visit, The following deficiency was cited per California Code of Regulations, Title 22, Division 6, Chapter 8.
An exit interview was conducted, a copy of the 809, 809-D and appeals rights were provided via email to the Facility Designated Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2023 08:55 AM - It Cannot Be Edited


Created By: Arielle Pascua On 02/09/2023 at 11:50 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
80070(d)

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80070 Client Records
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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Licensee will review section cited 80070(d) to it's entirety. Licensee will provide a statement of correction and acknowledgement that he has read the cited section above. Licensee was able to provide facility files during the LPAs visit.
POC was cleared on 02/09/2023.
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This is not as evidenced by: Based on staff interview, the staff one shift stated they did not have access to client records. CCL was not able to obtain client records until the Administrator arrived at the facility. This poses a potential health,safety, and personal rights risk for the persons in care.
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Type B
02/23/2023
Section Cited
CCR80066(c)

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(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:
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Licensee will review section cited 80066(c) to it's entirety. Licensee will provide a statement of correction and acknowledgement that he has read the cited section above. Licensee was able to provide facility files during the LPAs visit.
POC was cleared on 02/09/2023.
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This is not as evidenced by: Based on staff interview, the staff one shift stated they did not have access to client records. CCL was not able to obtain client records until the Administrator arrived at the facility. This poses a potential health,safety, and personal rights risk for the persons 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/10/2023 08:55 AM - It Cannot Be Edited


Created By: Arielle Pascua On 02/09/2023 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
80064(b)

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80064 Administrator-Qualifications
(b) Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator.
This is not as evidenced by:
Based on LPA observation during unannounced visit the staff on shift was unable to provide CCL staff access to review facility documentation.
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Licensee will review section cited 80070(d) to it's entirety. Licensee will provide a statement of correction and acknowledgement that he has read the cited section above to the LPA by POC date 02/23/2023 to the LPAs email arielle.pascua@dss.ca.gov

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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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