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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 07/07/2023
Date Signed: 07/11/2023 08:04:46 AM

Document Has Been Signed on 07/11/2023 08:04 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:
07/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Norma BorgusTIME COMPLETED:
03:00 PM
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On 07/07/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Kesha Lewis arrived unannounced to this facility to conduct as Plan of Correction (POC) visit. LPA Pascua and Lewis were greeted by staff member, Norma Borgus and asked to call the Facility Designated Administrator, Julian Hawes to let him know that CCL was present at this time. LPA Pascua was informed that FDA Hawes could not make the visit and and asked LPAs to continue the visit with SM Borgus. Current Census was 4.

The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 06/30/2023 from a prior visit conducted on 06/29/2023.

As of the date of this visit, 07/07/2023, the department had not received any forms or documents to support the plan of the correction and has not been completed by this facility and its designated Administrator at this time.



An immediate civil penalty in the amount of $1,500 was assessed for violations of 80044(a)(2) and 85064(j)(3). This civil penalty was due to failure to correct the Plan of Correction by the POC date on 06/30/2023. The Facility Designated Administrator was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.

An exit interview was conducted, a copy of this report, and appeals rights was provided to the Facility Designated Administrator,Julian Hawes. An electronic email read receipt confirms receiving these documents.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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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