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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 02/21/2024
Date Signed: 02/21/2024 05:14:30 PM

Document Has Been Signed on 02/21/2024 05:14 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
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:
02/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Andrea Rush TIME COMPLETED:
12:00 PM
NARRATIVE
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On 02/21/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct a quarterly non-compliance visit. LPA was greeted by House Manager (HM), Andrea Rush and explained the purpose of the visit. LPA asked that HM Rush call the Facility Designated Administrator, Norma Borges, to inform them that CCL was present at this time. FDA Borges arrived at the facility at 11:04am.

Current Census was 3. 1 out 3 residents were observed to be outside in the sun sleeping. 2 out 3 residents were out at their respective day program.

The purpose of this visit is to conduct a quarterly visit in response to a Non-Compliance meeting that was conducted with the facility on 07/11/2023.

LPA reviewed 3 resident files. LPA reviewed 3 staff files. It was observed that 2 out 3 staff files reviewed did not have a current TB test on file.
LPA reviewed Medication Records for all residents.

A tour of the facility was conducted.
It was observed that the facility thermometer was not turning on at the time of the visit. The facility called Home shield at the time of the visit to set an appointment to fix the thermometer.
LPA toured 3 resident bedrooms. One resident bedroom is a share bedroom with an adjoining bathroom. All furniture and furnishing was observed to be in compliance at this time. LPA reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPAs observed laundry room where it was observed that detergent, laundry room and all cleaning supplies were locked and made inaccessible at this time. Knives were observed to be locked and made inaccessible. A tour of the bathrooms were conducted, hot water temperature was taken to ensure regulatory requirements. A tour of the living room, garage, office, and all other areas intended for resident use was conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DREAM CARE
FACILITY NUMBER: 502700754
VISIT DATE: 02/21/2024
NARRATIVE
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Hot water temperature was taken and was observed to be at 101.1. LPA was notified that the facility will call out a company to check the water heater to ensure that the hot water was within Title 22 regulations.

A technical violation was provided for 80088(e)(1) and 80061(a).

Based on the observations made during today's visit, 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 was given end the of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2024 05:14 PM - It Cannot Be Edited


Created By: Arielle Pascua On 02/21/2024 at 11:42 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: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
80065(g)(1)

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(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
This is not met as evidenced by:
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The administrator stated that the facility staff will conduct TB tests for both staff members. A copy of each TB test will be provided to the LPA after testing. A statement of correction and acknowledgement will be provided to the LPA by the POC Date 02/22/2024.
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Licensee did not ensure that 2 out 3 staff did not have a TB test one year prior to their employment to the facility. LPA observed in 2 out 3 staff files that the last TB tests for staff were on 02/12/2021 and 04/20/2022. The 2 staff members were employeed 12/2023. This is an immediate health, safety and personal rights risks to persons 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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
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