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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 08/01/2024
Date Signed: 08/01/2024 05:10:42 PM

Document Has Been Signed on 08/01/2024 05:10 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DREAM CARE #2FACILITY NUMBER:
502701078
ADMINISTRATOR/
DIRECTOR:		NORMA BORGESFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 3DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Nadia Falconer, House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 08/01/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility and was met first by Latonielle S. Gurdon, Direct Service Provider (DSP) and by Nadia Falconer, House Manager. LPA Campbell explained the purpose of the visit. Both staff were cleared and associated to the facility.

Upon entry, LPA Campbell observed a resident getting something to drink from the kitchen. Another resident returned to the facility after receiving a haircut. House Manager Nadia Falconer then provided access to files for review. The facility currently has a census of 3 residents. All 3 resident files were reviewed and found to be complete. There are 5 staff working in the facility.. LPA Campbell reviewed 4 of the staff files and observed that they were complete.

The Facility is located in a one story building with 3 bedrooms and 2 bathrooms. It is licensed to house up to 4 ambulatory residents from 18 to 59 years of age who are developmentally disabled. Upon entry there is a short hallway. Immediately to the left is a hallway to Bedroom 1, the laundry room, Bathroom #2 and Bedroom #2. Upon turning right after entering the facility, is a living room, kitchen and dining room. Bedroom #3 is toward the back of the home and connected to Bathroom #1. Pathways are unobstructed. LPA Campbell observed clothes were put away, beds were made and no debris was observed on the tables, chairs or floors.

LPA Campbell observed enough fresh perishables to last more than three days. There were enough pantry non-perishables to last more than 7 days. The freezer was measured at -5 degrees Fahrenheit and the refrigerator was set at 38 degrees Fahrenheit. Sharps and first aid were locked and inaccessible to residents. The thermostat was set at 74 degrees Fahrenheit and the fire extinguisher was last inspected on 06/18/24.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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 2
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 #2
FACILITY NUMBER: 502701078
VISIT DATE: 08/01/2024
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Based on observation, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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