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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 08/30/2022
Date Signed: 09/06/2022 10:44:26 AM

Document Has Been Signed on 09/06/2022 10:44 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 CARE #2FACILITY NUMBER:
502701078
ADMINISTRATOR:HAWES, JULIANFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Norma BorgesTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 08/30/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver Norma Borges who was requested by this LPA to go ahead and contact the facility designated Administrator to inform him that CCL was present at this time. The facility designated Administrator, Julian Hawes, arrived shortly thereafter to this facility and was briefly interviewed. It was learned that there were (2) residents present at this time with (2) additional residents out at their respectable day programs.
Current census was 4 residents.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Julian Hawes.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe an additional food storage unit which was present and functional at this time in the garage area.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.
Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 502701078
VISIT DATE: 08/30/2022
NARRATIVE
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Garage area was toured. This area was used to house additional furniture and supplies for the facility residents.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located in facility living area, was observed to have been annually inspected on 06/14/2022 by the local fire extinguisher company, Jorgensen, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator Julian Hawes at this time.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/06/2022 10:44 AM - It Cannot Be Edited


Created By: Charlie Yang On 08/30/2022 at 01:32 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DREAM CARE #2
FACILITY NUMBER: 502701078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since there was not a sufficient supply of 7-days nonperishable food quantities at all times maintained on premises which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Facility designated Administrator stated that additional non perishable food quantities will be purchased. A statement of correction will be completed, along with a copy of the additional food receipts, will be submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/06/2022 10:44 AM - It Cannot Be Edited


Created By: Charlie Yang On 08/30/2022 at 01:32 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DREAM CARE #2
FACILITY NUMBER: 502701078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above since the kitchen drawer, refrigerator door handle, and bathroom faucet were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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The facility designated Administrator stated that these items will be repaired/replaced. A statement of correction, along with photos of the items repaired/replaced, will be completed and submitted into CCL by the due date of 09/06/2022.
Deficiency Dismissed
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [2] out of [3] sliding glass doors did not have a functional screen in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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The facility designated Administrator stated services will be contracted to repair/replace both (2) sliding glass door screens to make sure that they are functional and in good repair. A statement of correction will be completed, along with a copy of receipts for services rendered, to be submitted into CCL by the due date of 09/06/2022.
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:Stephenie Doub
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022


LIC809 (FAS) - (06/04)
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