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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700754
Report Date: 08/14/2024
Date Signed: 08/15/2024 07:37:46 AM

Document Has Been Signed on 08/15/2024 07:37 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/
DIRECTOR:		NORMA BORGESFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Kenroy Anderson TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 08/14/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit. LPA met with Staff member (SM), Paciencia Castro and Alexander Lugtu. LPA asked that they notify House Manager (HM), that CCL was present at this time. LPA was able to speak with House Manager (HM), Kenroy Anderson to notify him that CCL was present. LPA was informed that HM Anderson was the individual in charge of the facility and was in a meeting at this time but will be able to meet the LPA in 30 minutes. At 11:15am, LPA met with HM Anderson and explained the purpose of this visit. Current census was 4. A brief interview with HM Anderson was conducted.

The purpose of this visit was to follow up on the Facility Designated Administrator. On On 08/08/2024, it was learned that the Facility Designated Administrator (FDA), Norma Borges was separated on the staff roster on 06/17/2024. LPA conducted a phone call with former administrator who also confirmed that they provided their notice sometime in June 2024 and no longer work at this facility. LPA reviewed facility records which confirm that the department was not notified that the current administrator on file no longer worked at this facility. On 08/08/2024 at 10:23am, LPA Pascua emailed Licensee Julian Hawes to inform him that there currently no certified administrator at this facility. LPA Pascua asked Licensee Hawes to provide supplemental paperwork to designate a new administrator to the LPA email by 08/13/2024 at 5:00pm. As the date of this visit, 08/14/2024, this LPA has not received any paperwork to designate a new certified Administrator. LPA requested that the following paperwork to be submitted to the LPA at arielle.pascua@dss.ca.gov by 08/15/2024 to designate a new administrator at the facility:

· A letter from the licensee or Board appointing the new Administrator


· LIC 308
· A copy of the current Administrator Certificate
· Any documentation meeting the education and/or experience requirements
· LIC 200 signed by the licensee or designee
· LIC 500
· LIC 501
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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Document Has Been Signed on 08/15/2024 07:37 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/14/2024 at 10:45 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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
80063(a)

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(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.
This is not met as evidenced by:
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The facility will provide complete documentation to the LPA by 08/15/2024 at 5:00pm. In addition, Licensee shall send in a written statement of acknowledgement that he has read the cited section to it’s entirety but the POC due date.
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Based on observation, interview, and record review, the Licensee did not ensure that the facility had general supervision of the licensed facility by not ensuring that there was a certified administrator on file with the department. LPA Pascua reviewed the Guardian roster and found that the Facility Designated Administrator was separated from this facilities staff roster on 06/17/2024. LPA emailed Licensee to resolve this issue, however has not obtained paperwork to designate a new administrator by the due date of 08/13/2024. This poses an immediate health, safety and personal rights risks to persons in care.
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Type A
08/15/2024
Section Cited
CCR85061(b)

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(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Such notification shall include the following:
This is not met as evidenced by:
Based on interview and record review, the Licensee did not ensure to inform the department of a change of administrator.
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Licensee shall review section, 85061(b). A statement of correction will be submitted to the LPA's email at arielle.pascua@dss.ca.gov by 08/15/2024 at 5:00pm.
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. LPA reviewed the Guardian roster and found that the Facility Designated Administrator was separated from this facilities staff roster on 06/17/2024. LPA contacted this staff member who confirmed that they provided their 2 week notice in June and no longer works at this facility. This poses 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: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


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: 08/14/2024
NARRATIVE
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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: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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