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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701078
Report Date: 01/09/2025
Date Signed: 01/09/2025 01:59:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20241009141151
FACILITY NAME:DREAM CARE #2FACILITY NUMBER:
502701078
ADMINISTRATOR:NORMA BORGESFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: ZIP CODE:
95351
CAPACITY:4CENSUS: 3DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nadia Falconer, House ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained unexplained bruising while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/09/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility for a complaint. LPA Campbell met with Nadia Falconer and explained the purpose of the visit.

Regarding the allegation that a client sustained unexplained bruising while in care, the bruise was observed by R1’s day program on October 1, 2024. S1 stated that the source of the bruise was unknown and assumed to be from behaviors exhibited from the prior weekend. R1's responsible party confirmed that they had received the same information from the facility.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit.
An exit interview was conducted, and copies of the report and appeal rights left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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-20241009141151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072(a)(2) Personal Rights - ...each client shall have personal rights which include, but are not limited to....(2) To be accorded safe, healthful and comfortable accommodations, ...t to meet his/her needs.. This requlation is not met as evidenced by
1
2
3
4
5
6
7
The facility will create a plan to consistentlly conduct a physical survey of clients with their permission for possible injuries. The facility will also log the scheduled surveys and their findings. The template forms and scheduled plan will be presented to LPA Campbell via email at renee.campbell@dss.ca.gov
8
9
10
11
12
13
14
The facility was unable to account for how a bruise occurred on R1's arm.
8
9
10
11
12
13
14
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: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20241009141151

FACILITY NAME:DREAM CARE #2FACILITY NUMBER:
502701078
ADMINISTRATOR:NORMA BORGESFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: ZIP CODE:
95351
CAPACITY:4CENSUS: 3DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nadia Falconer, House ManagerTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not report unexplained bruising while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/09/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility for a complaint. LPA Campbell met with Nadia Falconer and explained the purpose of the visit.

Regarding the allegation that facility did not report unexplained bruising while in care, there was an Unusual Incident Report (UIR) sent to the Department and Valley Mountain Regional Center (VMRC) on 10/03/24. The copy for the department was given to LPA Campbell during the visit on 10/08/2024.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Nadia Falconer.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3