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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 11/13/2023
Date Signed: 11/14/2023 08:27:16 AM

Document Has Been Signed on 11/14/2023 08:27 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DREAM CAREFACILITY NUMBER:
502700754
ADMINISTRATOR:NORMA BORGESFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
11/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julian HawesTIME COMPLETED:
11:30 AM
NARRATIVE
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On 11/13/2023, an Office meeting was conducted on this day by the Sacramento South Regional Office via Microsoft Teams. The purpose of this office meeting was to follow up on a complaint investigation received by the department on 1/17/2023 regarding the facility safeguarding P&I funds. Present at the meeting resent at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Managers (LPMs), Lisa Rios and Liza King , Licensing Program Analyst (LPA), Arielle Pascua, and Representing the facility, Licensee, Julian Hawes, and Jacob Reinhardt.

On 1/17/2023, the Sacramento South Regional Office received a complaint in regards to safeguarding P&I funds at the facility, and a trust audit was requested and conducted by the Department’s Audit Section. During the course of the investigation, LIC 405, Money Network Ledgers and minimal receipts were reviewed for all clients. The department was unable to prove that the facility was not safeguarding P&I funds, however, the licensee did not maintain adequate receipts for two residents in care.

Based on the information above, per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, and a copy of the report will be given.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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 11/14/2023 08:27 AM - It Cannot Be Edited


Created By: Arielle Pascua On 11/13/2023 at 10:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2023
Section Cited
CCR
80026(h)(1)

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(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
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Licensee stated that a review of the following Section will be reviewed. Licensee stated that staff will be provided a new plan to ensure that receipts and ledgers are current and up to date. A copy of the new plan shall be sent to the LPA by the POC date 12/13/2023.
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This is not met as evidenced by: Based on audit findings, the licensee did not ensure that all receipts for 2 out 4 residents were maintained. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/13/2023
Section Cited
CCR80064(a)(3)

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(a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.
This is not met as evidenced by:
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Licensee shall provide a statement of acknowledgement to the LPA by the POC date 12/13/2023.
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, Based on audit report findings, the licensee did not ensure administrator followed their policies of the facility which poses a potential health, safety, and personal rights risk to residents in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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