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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 07/31/2023
Date Signed: 08/02/2023 08:51:27 AM

Document Has Been Signed on 08/02/2023 08:51 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:
07/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Andrea Rush TIME COMPLETED:
02:30 PM
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
On 07/31/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a case management visit. LPAs met with Staff Member (SM), Andrea Rush and explained the purpose of the visit. LPA Pascua asked that SM Rush call the Facility Designated Administrator (FDA), Julian Hawes, and inform him that Community Care Licensing was present at the facility and inform him of the purpose of the visit. It was learned that FDA Hawes was unable to come at the facility at this time. LPAs continued the visit with SM Rush. There was one other staff member present at the time of this visit, Alma Moyamoy.

Current census was 4.

During a Plan of Correction (POC) visit conducted on 07/31/2023, LPAs Pascua and Valerio observed a grayish white child lock on the front doorknob. LPAs asked why the child lock was on the door and was told by SM Rush that it was due to a resident continually leaving the facility. LPAs asked SM Rush if the facility had a plan in place for implementation of the child lock. SM Rush advised that the facility has been in contact with the Service Coordinator (SC) but does not have a plan at this time.

A civil penalty of $1,000 is being issued during today's visit for violation of Section 80070(a). This civil penalty was due to being a repeat violation. This facility was cited for the same section on 02/09/2023.

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 and 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: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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 08/02/2023 08:51 AM - It Cannot Be Edited


Created By: Arielle Pascua On 07/31/2023 at 01:12 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: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
80020(a)

1
2
3
4
5
6
7
80020(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This is not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall provide a provide a statement of correction and acknowledgement that they have read the following section 80020(a) to it's entirety to the LPA by the POC date. The child lock was taken off during the visit.
8
9
10
11
12
13
14
Based on observation and interview, the Licensee did not ensure that residents were able to leave and exit the facility. LPAs observed a grayish-white child lock on the door which probihited residents to leave the facility. This poses an immediate health, safety and personal rights risk to persons 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: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


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