<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:43:18 PM

Document Has Been Signed on 06/01/2023 05:43 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:
06/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julian Hawes TIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a case management visit. LPAs were greeted by staff member, Andrea Rush and explained the purpose of the visit. LPAs asked that SM Hull contact the Facility Designated Administrator (FDA) at this time to inform them that CCL was present. LPA Pascua spoke to FDA Julian Hawes and it was learned that he was unable to come to the facility at this time and could continue the visit with SM Andrea Rush. There was one other staff member present at the facility, Alma Moyamoy.
Current census was 4. A tour of the facility and a brief interview with SM Rush were conducted
The purpose of this case management visit is to follow up on documentation that was requested by the Audits department.
LPA Pascua requested the following documents:
  • Copy of the internal investigation completed by the facility involving staff 1 (S1) and a client.
  • Ledgers and receipts for clients for January 2022 to current for the clients that facility handled their cash resources (P&I)
  • Procedures for cash handling of client’s P&I, including where clients cash is specifically located.
  • Copy of the surety bond
  • Copies of physicians report and admission agreements for all clients
LPA Pascua requested that the following documents to be sent to the Audits Department or the LPA's email at arielle.pascua@dss.ca.gov by 06/08/2023 at 5:00pm. Licensee was informed that failure to provide documentation may result in deficiencies.
During the visit LPAs observed that there was a black padlock on the refrigerator door. It was stated by staff that a resident likes to drink milk and juice consistently. LPA reviewed the resident's IPP and confirmed with staff that there is not a plan for the locked refrigerator door at this time.
Based on observations made at today's visit The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to the facility via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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 2
Document Has Been Signed on 06/01/2023 05:43 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/01/2023 at 01:21 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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
80076(4)

1
2
3
4
5
6
7
( 4) Between meal nourishment or snacks shall be available for all clients unless limited by dietary restrictions prescribed by a physician.
This is not met as evidenced by: The facility locked non-perishable food supply in pantry not allowing immediate access for residents.
1
2
3
4
5
6
7
Facility Administrator stated that a review of the section, 80076(4), will be conducted. A statement of correction will be provided to the LPA's email at arielle.pascua@dss.ca.gov by the POC date 06/30/2023 .
The lock was taken off at the time of the visit.
8
9
10
11
12
13
14
Based on observation, and interviews licensee locked the facility pantry which did not ensure immediate access to food supply. This poses a potential health, safety, personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2