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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 08/16/2021
Date Signed: 08/16/2021 05:20:39 PM

Document Has Been Signed on 08/16/2021 05:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DREAM CARE #2FACILITY NUMBER:
502701078
ADMINISTRATOR:HAWES, JULIANFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 0DATE:
08/16/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julian HawesTIME COMPLETED:
12:30 PM
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Announced Prelicensing visit conducted on 08/16/2021 by LPA Charlie Yang out to this facility and was met by the Applicant, Julian Hawes, who was briefly interviewed.
There weren't any residents in care at this time. Tour of this facility was conducted.
Common areas were toured. Living room, dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time.
Resident bedrooms were toured. Bedroom furniture and furnishings were observed to be functional and able to meet the needs of the residents at this time. Linen closet was observed to contain linens and supplies sufficient to meet the needs of the residents at this time.
Resident restrooms were toured. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Garage area was toured. Cabinet storing hygiene items was observed to be locked and made inaccessible at this time. Laundry room was toured and observed to be locked and made inaccessible at this time.
Kitchen area was toured. Cabinets and drawers storing pots, pan, and dinnerware were reviewed and observed to be functional and able to meet the needs of the residents at this time.
Food storage was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time.
First aid kit was observed to be present and contained all required components at this time.
Fire extinguisher, located in office area, was observed to have been annually inspected by the local fire extinguisher company and in compliance at this time.
A review of the sample resident, personnel, and medication log records was conducted.
A tour of the exterior grounds was conducted. A review of the perimeter, side, and emergency exits was conducted.
Based on a review of this facility during today's Prelicensing visit, this facility has been found to be in compliance.
This Applicant will be waived for the Component III interview since it has already been completed with the initial licensure of another licensed care facility. Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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