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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 06/02/2023
Date Signed: 06/14/2023 12:02:51 PM

Document Has Been Signed on 06/14/2023 12:02 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:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Andrea RushTIME COMPLETED:
03:30 PM
NARRATIVE
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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 Rush contact the Facility Designated Administrator (FDA) at this time to inform them that CCL was present. SM Rush was unable to contact FDA Julian Hawes via telephone. LPA proceeded the visit with SM Rush.
Current census was 4.There was one other staff member present, Alma Moyamoy.

A complaint was received by the department alleged that the facility did not administer medication as prescribed. It was learned through the investigation that during two separate outings the resident did not receive the correct amount of medication. On 10/22/2023, the resident went home for their first home visit and it was observed by family during medication administration that the medication provided to the resident was another resident's medication box. On 11/23/2023, the resident went home for a second visit and when night medications were provided it was observed that only one pill was available for a 3 night visit. The responsible party reached out to the facility and it was learned that the facility did not provide the resident with their refill. The responsible party was able to obtain extra medication for the remainder of the nights to ensure that the resident was given their medication on time.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of 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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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 06/14/2023 12:02 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/02/2023 at 01:17 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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/05/2023
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This is not met as evidenced by: The facility did not ensure that the resident was asissted with their prescription medication. Based on interview, the facility did not provide the
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Facility Administrator stated that a review of the section, 80075(b), 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
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resident with the correct amount of medication during their outings while out of the facility. This causes an immediate risk to health, safety, personal rights risk to the persons in care.
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arielle.pascua@dss.ca.gov. by the due date of 06/05/2023 COB. Information submitted must include attendees, trainers, and information discussed.

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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: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


LIC809 (FAS) - (06/04)
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