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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 09/30/2022
Date Signed: 10/04/2022 10:16:35 AM

Document Has Been Signed on 10/04/2022 10:16 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:
09/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ednita GardenhireTIME COMPLETED:
02:00 PM
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Unannounced Plan of Correction visit made out to this facility on 09/30/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated personnel Ednita Gardenhire who contacted the facility designated Administrator Julian Hawes to inform him that CCL was present at this time.
Brief interview was conducted with Ednita Gardenhire.
Current census was 4 residents.
The purpose of this visit was to follow up on the plan of correction that was due from prior annual visit dated on 08/30/2022 with the following deficiencies:
  • Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

  • The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

  • All window screens shall be in good repair and be free of insects, dirt and other debris.


As of the date of this visit on 09/30/2022 there has not been any submission of a plan of correction for the above cited deficiencies.
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and copy was given to facility personnel Ednita Gardenhire.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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 3
Document Has Been Signed on 10/04/2022 10:16 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/30/2022 at 01:32 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: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
85076(d)(1)

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 Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
Based on observation, the licensee did not comply with the section cited above since there was not a sufficient supply of 7-days nonperishable food quantities at all times
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Facility designated representative stated that additional non perishable food quantities will be purchased. A statement of correction will be completed, along with a copy of the additional food receipts, will be submitted into CCL by the due date of 10/04/2022.
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maintained on premises which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/04/2022
Section Cited
CCR80087(a)

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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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The facility designated personnel stated that these items will be repaired/replaced. A statement of correction, along with photos of the items repaired/replaced, will be completed and submitted into CCL by the due date of 10/04/2022.
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Based on observation, the licensee did not comply with the section cited above since the kitchen drawer, refrigerator door handle, and bathroom faucet were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/04/2022 10:16 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/30/2022 at 01:39 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: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited
CCR
80088(b)

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All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
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The facility designated personnel stated services will be contracted to repair/replace both (2) sliding glass door screens to make sure that they are functional and in good repair. A statement of correction will be completed, along with a copy of receipts for services rendered, to be submitted into CCL by the due date of 10/04/2022.
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Based on observation, the licensee did not comply with the section cited above in [2] out of [3] sliding glass doors did not have a functional screen in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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