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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 10/08/2024
Date Signed: 10/08/2024 10:41:37 AM

Document Has Been Signed on 10/08/2024 10:41 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
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: 4DATE:
10/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nadia Falconer, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management - health and safety visit. LPA Campbell met with facility staff Nadia Falconer and explained the purpose of the visit.

On 10/02/2024, LPA Campbell was informed that one employee was to be excluded from the facility as of 10/07/24. LPA Campbell inspected the physical plant, including the living area, and exterior plant to ensure excluded employee were not on the premises on 10/08/2024. During the visit, LPA Campbell did not observe this individual.

LPA spoke to Resident 1 (R1) and staff during the visit. LPA Campbell searched the Guardian System Roster for Dearm Care #2. LPA observed staff on shift to be fingerprint cleared and associated to the facility.

LPA observed R1 and Resident 2 (R2) to be up and walking around the facility. Staff were observed assisting R1 and R2 with their needs and socializing.

No immediate health or safety concerns were observed during this visit.

LPA Campbell provided guidance to staff regarding disassociating excluded staff from the facility.

An exit interview was held, and a copy of the report was provided. A copy of the order excluding the former staff was left as well.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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