<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701078
Report Date: 03/23/2022
Date Signed: 03/25/2022 02:03:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2022 and conducted by Evaluator Charlie Yang
COMPLAINT CONTROL NUMBER: 27-AS-20220317123924
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:
03/23/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monica Abrica and Norma BorgesTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff present in the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Unannounced complaint visit made out to this facility on 03/23/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility manager, Monica Abrica, and facility caregiver, Norma Borges, who were both briefly interviewed.
Current census was 4 residents.
This LPA requested for a current facility roster for this care home from the facility manager Abrica. A review was conducted from the copy of the facility personnel roster given to this LPA against the LIS 536 dated on 03/22/2022.
Based on a review of the facility roster and licensing information comparison, it was observed that there was a staff person, S1, currently employed by this facility who was not properly fingerprint cleared and properly associated to this facility.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220317123924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

A civil penalty was issued in the amount of $100 for violation of criminal background rules and regulations on the LIC 421BG.

A copy of the appeal rights was printed and a copy was left at this facility with the facility manager Abrica.

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

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220317123924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/24/2022
Section Cited
CCR
87355(e)(2)
1
2
3
4
5
6
7
Criminal Record Clearance

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance as specified in Section 87355(c) or
1
2
3
4
5
6
7
The facility manager stated that an audit of all staff records will be conducted. In addition, all forms and documents will be completed and submitted into CCL to properly associate, any and all, facility staff to make sure that they are all properly fingerprint cleared and associated.
A statement of correction, along with all
8
9
10
11
12
13
14
This facility was deficient as observed that a facility staff person was not properly fingerprint cleared and properly associated to this facility prior to employment. This posed an immediate threat to the health, safety, and personal right of the residents in care.
8
9
10
11
12
13
14
required forms and documents, will be completed and submitted into CCL by the due date of 03/24/2022.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3