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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 06/26/2023
Date Signed: 06/28/2023 10:39:11 AM

Document Has Been Signed on 06/28/2023 10:39 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:
06/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Andrea Rush TIME COMPLETED:
01:30 PM
NARRATIVE
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On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to conduct a complaint visit. LPAs were greeted by Staff Member (SM) Andrea Rush and explained the purpose of the visit. LPA Pascua asked that SM Rush call the Facility Designated Administrator (FDA) and inform them that CCL was present at this time. LPA Pascua learned that FDA, Julian Hawes, was unable to make it to the facility at this time. LPAs continued the visit with SM Rush. The purpose of this visit was to deliver complaint findings for the allegations above.

During a complaint investigation (27-AS-20230223083540), which was found to be substantiated, it was discovered that the facility did not provide a verbal or written notice regarding Resident 1(R1) eviction to the department. This poses a potential health and safety risk to residents in care.

Due to the facility being cited on 06/26/23 for 80061 Reporting Requirements on a separate complaint visit, no citation will be given on this visit. Please see complaint report on 06/26/2023.

An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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