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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:36:16 PM

Document Has Been Signed on 04/21/2023 02:36 PM - 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:
04/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julian Hawes TIME COMPLETED:
12:30 PM
NARRATIVE
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On 04/20/2023 at 11:50am, Licensing Program Analysts (LPAs) Arielle Pascua and Avellina Martinez arrived unannounced to this facility to conduct a case management visit. LPA Pascua knocked on the facility door twice and no one answered the facility door. At 11:57am, LPA Pascua called Facility Designated Administrator, Julian Hawes and was unable to reach the FDA at this time. LPA was unable to leave a message due to the voicemail box being full.

On 04/21/2023 at 8:00am, Regional Manager (RM) Stephenie Doub and Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a complaint visit. RM and LPA were greeted by staff member, Alma Moyamoy and explained the purpose of the visit. RM and LPA asked SM Moyamoy to call the Facility Designated Administrator to inform them that CCL was present. Upon waiting for the Facility Designated Administrator (FDA), at 8:10am, LPA and RM observed an unlocked padlock on the black medication cabinet located in the office. In addition, LPA and RM observed a resident's bubble pack located in a Minnie Mouse bag on the top of the black office desk. At 8:20am, RM and LPA met with FDA Julilan Hawes. There were two other staff members present, Iboni James and Jada Hull.



Current Census was 4. 1 out of 4 residents were out at their respective day program.
On 04/05/2023 at 10:00am, LPA Pascua and Licensing Program Manager (LPM) Emerita Curiel arrived unannounced at the facility to conduct a complaint visit. At 10:02am, LPA Pascua and LPM Curiel were greeted at the door by Staff 1 (S1) and asked that they call the Facility Designated Administrator to inform that that CCL was present. At 10:05am, S1 closed the door and did not allow LPA Pascua or LPM Curiel into the facility and stated that they would call FDA. At 10:10am, LPA Pascua knocked on the door to see if S1 notified the FDA that CCL was here. LPA Pascua was unable to get a staff member to open the door. At 10:11am, LPA Pascua called FDA and was not able to reach the FDA at this time. At 10:12am, LPA Pascua received a call from the FDA and informed them that CCL was present. It was stated that they were not informed by S1 that CCL was present and would be at the facility in 2 minutes. At 10:15am, LPA Pascua and LPM Curiel met with FDA Hawes and were able to obtain entrance to the facility.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 04/21/2023 02:36 PM - It Cannot Be Edited


Created By: Arielle Pascua On 04/20/2023 at 09:11 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2023
Section Cited
CCR
80044(a)(2)

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80044(a)(2) Inspection Authority of the Licensing Agency
(2) Health and Safety Code Section 1533 provides in part:
...any duly authorized officer, employee, or agent of the State Department of Social Services may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter.
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An immediate civil penalty is hereby issued on 04/21/2023 in the amount of $500 due to the LPA and LPM were refused entry into the facility at the time of requested inspection.
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This requirement was not met as evidenced by:
Based on observation, LPA and LPM was denied entry to the facility around 10:00am. S1 opened the facility door and LPA and LPM identified themselves as individuals from licensing. LPA asked that they call the Facility Designated Administrator that CCL was present. S1 shut the door and did not allow LPA and LPM entry to the facility. This poses an immediate health and safety risk to the persons in care.

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Licensee agrees to send in a written statement of acknowledgement that he has read the cited section to it’s entirety to the LPA’s email at Arielle.pascua@dss.ca.gov by 04/22/2023 at 5pm.
Type A
04/22/2023
Section Cited
CCR85064(j)(3)

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85064
Adminstrator Qualifications and Duties
(j) The administrator shall perform the following duties:(3) Recruitment, employment and training of qualified staff, and termination of staff.
This is not met as evidenced by:
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Facility Administrator stated that a review of the section, 85064(j)(3), will be conducted. A statement of correction, along with 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
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Based on observation, LPA and LPM were denied entrance by S1 when they identited themselves as individuals from the licensing agency. This poses an immediate health and safety risk to the persons in care.
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by the due date of 04/22/2023 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.
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: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/21/2023
NARRATIVE
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Based on the observations made during the course of this visit and a complaint visit on 04/05/2023 the following deficiencies were cited per the California Code of Regulations, Title 22 and Health and Safety Code. An immediate civil penalty of $500 was assessed during this case management visit today, on 04/21/2023, for a violation of Section 80044(a)(2). The Facility Designated Administrator was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.

Exit interview was conducted and copy of the 809, 809D, and appeals rights were emailed to the Facility Designated Administrator at the end of the visit. An electronic response from FDA Hawes confirms receipt of this report.

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

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/21/2023 02:36 PM - It Cannot Be Edited


Created By: Arielle Pascua On 04/21/2023 at 08:47 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2023
Section Cited
CCR
85064(f)

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85064(f)
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.
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Facility Administrator stated that a review of the section, 85064(f), will be conducted. A statement of correction, along with 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
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This is not met as evidenced by:
Based on LPA observation, the licensee did not comply with this cited section 85064(f) by absent during the LPA's visit. In addition, there was not an authorized represenative during the visit n 04/20/2023. This is an immediate health and safety concern to the persons in care.
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by the due date of 04/22/2023 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.
Type A
04/22/2023
Section Cited
CCR80075(k)(1)

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 (k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This is not met as evidenced by:
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Facility Administrator stated that a review of the section, 80065(k)(1), will be conducted. A statement of correction, along with 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
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Based on LPA and RM observation, the licensee did not ensure that the resident's medication was locked and made inaccesible to the residents in care. LPA and RM observed that the medication pad lock was not locked and medication was placed in a bag on top of the office desk. This an an immediate health and safety concern to the persons in care.
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by the due date of 04/22/2023 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed.
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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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