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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 07/24/2023
Date Signed: 07/25/2023 08:27:20 AM

Document Has Been Signed on 07/25/2023 08:27 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:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Norma Borges TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arielle Pascua and LPA Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Norma Borges, and explained the purpose of the visit. LPAs informed facility staff to inform facility Administrator Julian Hawes. Administrator Julian verbally designated facility staff to carry out the rest of the visit and sign on his behalf. Current census was 4. 2 out of 4 residents were out at their respective day programs.

The facility is licensed for a capacity of 4 adults age range 18 through 59 and approved for 4 ambulatory only. Administrator on file is Julian L Hawes; Administrator Certificate #6052806735 Expiration 7/29/2023. LPAs toured the physical plant to ensure compliance with Title 22 regulations. Residents have access to all areas except the locked medication cabinet, locked cleaning supplies, and locked facility files.

LPA and facility staff Norma inspected the common areas, resident bedrooms, bathrooms, and exterior plant. Common areas included the dinning room, living room/visitor area, and hallways. Common areas were observed to be clean, organized, and free from debris. Technical Advisory was provided to facility staff due to the floors peeling off in multiple areas from wear and tear. No emergency exits were obstructed. The temperature in the facility was observed to be 71.0*F. Hot water was measured at 106.7 *F, which is within the regulatory range of 105 – 120 degrees Fahrenheit. Resident bedrooms were observed to be clean, organized, and have necessary furniture and furnishings. Bathrooms were observed to have soap, paper towels, toilet paper, and lidded trash cans. The medication cabinet was observed to be locked. Facility staff was observed to take out insulin from the facility refrigerator, which also stored client food items. The insulin was enclosed in a lock box, which is said to be accessible to only staff. Carbon monoxide and smoke alarms were observed to be in good repair. Fire extinguisher was serviced by Jorgenson Co. on 06/12/2023 and is in compliance at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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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: 07/24/2023
NARRATIVE
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LPAs reviewed 4 resident files. LPAs observed 4 resident files. 2 out 4 residents files were incomplete or had files that were not updated annually as required by Title 22 regulations. Resident 1 (R1) file was observed to have an LIC 602 Physician’s Report dated 03/29/2022. Resident 2 (R2) file was observed to have an Individual Program Plan (IPP) dated 05/11/2022. Resident 3 (R3) file was observed to have an Individual Program Plan (IPP) was last updated on 12/21/2022 and Individual Support Plan (ISP) was last updated on 04/10/2022. Administrator sent correspondence to VMRC representative Tony Chavez on 02/21/2023 at 11:28 AM stating the facility needed an updated IPP. Resident 4 (R4) file was observed to not have a pre-admission appraisal, Appraisal/Needs and Service Plan, and a Functional Capability Assessment located in the file.

LPAs reviewed 7 staff files, Staff 1 (S1) – Staff 7 (S7). LPAs observed 6 out 7 staff files to be incomplete and with files that are not up to date. S1, S2, and S3 had expired First-Aid Certificates. S4 and S5 files were observed to not have a copy in the file or did not complete Restricted Health Care Training - Diabetes. S2 did not have a file stating that DSP Year 2 training has been completed. S6 file was observed to not have DSP 1 and DSP 2 training completed. Guardian Background Check System and LIS Facility Personnel Report Summary was checked prior and during the facility annual inspection. LPAs did not observe S5 to be associated to the facility or poses a fingerprint clearance, which poses an immediate health and safety risk to resident in care. Due to S5 not being associated to the facility or possessing a fingerprint clearance, Facility staff and Administrator was made aware that a civil penalty is being assessed on 07/24/2023 in the amount of $500.00; the penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1522(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 80019(e) prior to working, residing or volunteering in the facility.

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility staff Norma Borges. An exit interview was held, and a copy of the report was provided in-person and sent via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/25/2023 08:27 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Arielle Pascua On 07/24/2023 at 01:43 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply by obtaining a criminal record clearance for S5 prior to working at the facility. This poses an immediate health, safety and personal risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Licensee will ensure that S5 will be removed and not scheduled to be present or employed at this facility until fingerprinted cleared and properly associated to the facility.
A statement of correction, along with proof of review for this section cited, 80019(e), will be completed and submitted into CCL by the POC Date.
Under Appeal
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by ensuring that 3 out 7 staff members had expired First Aid certificates. This poses an immediate health,safety or personal rights risks to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
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Licensee agrees to send in a written statement of acknowledgement that he has read the cited section to it’s entirety to the LPA’s email at Arielle.pascua@dss.ca.gov by POC date. In addition, Licensee will send a plan in place for S1, S2, and S3 to obtain First Aid Clearance by POC date.
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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/25/2023 08:27 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Arielle Pascua On 07/24/2023 at 01:43 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: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in by ensuring that 3 out 7 staff members obtained proper DSP training. This poses an immediate health,safety or personal rights risks to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee agrees to send in a written statement of acknowledgement that he has read the cited section to it’s entirety to the LPA’s email at Arielle.pascua@dss.ca.gov by POC date. In addition, Licensee will send a plan in place for S2 and S5 to obtain proper training by POC date.
Under Appeal
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that resident records were up to date. LPAs observed R1 did not have an updated Physicians reports. LPAs observed that did not have a pre-apprasial, no needs and services plan, and no functional ability assessment. This poses a potential health, safety and personal rights risks to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee agrees to send in a written statement of acknowledgement that he has read the cited section to it’s entirety to the LPA’s email at Arielle.pascua@dss.ca.gov by POC date. In addition, Licensee willsend a plan in place for R1 and R4 to obtain documents for resident records by POC date.
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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023


LIC809 (FAS) - (06/04)
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