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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:19:45 PM

Document Has Been Signed on 06/29/2023 04:19 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:
06/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Andrea RushTIME COMPLETED:
11:00 AM
NARRATIVE
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On 06/29/2023, Licensing Program Analysts (LPAs) Arielle Pascua, Christina Valerio and Arvin Villaneuva arrived unannounced to this facility to conduct as Plan of Correction (POC) visit. LPAs were greeted by staff member, Alma Moyamoy and asked to call the Facility Designated Administrator, Julian Hawes to let him know that CCL was present at this time. Shortly after, LPA Pascua spoke to staff member, Andrea Rush and informed LPA Pascua that she was going to a manager meeting. LPA Pascua asked who she may proceed the visit with. SM Rush stated she would inform the Facility Designated Administrator, Julian Hawes and inform me shortly. LPA Pascua was informed that FDA Hawes could not make the visit and asked LPAs to continue the visit with SM Rush. Current Census was 4. 3 out of 4 residents are out at their respective day programs.

Upon arrival, LPAs observed staff member, Alma Moyamoy, take a padlock off the refrigerator door. LPA Pascua asked why the refrigerator door was locked, SM Moyamoy stated that she put it on there. LPA Pascua reminded SM Moyamoy that a lock is not allowed on the door.LPA Pascua also observed the pantry to be locked and made inaccessible to the residents.

The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 06/16/2023 from a prior case management visit conducted on 06/15/2023.

As of the date of this visit, 06/29/2023, the department had not received any forms or documents to support the plan of the correction and has not been completed by this facility and its designated Administrator at this time.

A civil penalty in the amount of $1,200 was assessed for violations of Section 80044(c) for the time between 06/17/2023-06/29/2023. This civil penalty was due to failure to correct the deficiency by the Plan of Correction date. The Facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.

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: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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 06/29/2023 04:19 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/29/2023 at 10:40 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
80076(4)

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( 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.
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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.
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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.
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Type B
07/13/2023
Section Cited
CCR80087(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This is not met as evidenced by: Based on observation, the licensee did not ensure that the doorbell was in good repair. LPA Pascua rang the door bell several times
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Facility Administrator stated that a review of the section, 80087(a), 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 . Facility will provide receipt of repair by POC date 06/30/2023.
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and did not chime.
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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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
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