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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 10:15:59 AM

Document Has Been Signed on 10/04/2022 10:15 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ednita GardenhireTIME COMPLETED:
03:00 PM
NARRATIVE
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Unannounced Case Management 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 discussion was held, over the phone, with the facility designated Administrator Julian Hawes.
Brief interview was conducted with Ednita Gardenhire.
Current census was 4 residents.
The purpose of this visit was to follow up on the annual license fees that were due at this time. CCL records indicated that this facility license was effective on 08/25/2021 and a notice of payment was sent out to this facility on 06/01/2022. The due date for payment was 08/25/2022.
As of the date of this case management visit, 09/30/2022, this facility was still showing that the annual license fee had not been paid.

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 a copy was given to the facility designated 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)
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Document Has Been Signed on 10/04/2022 10:15 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Charlie Yang On 09/30/2022 at 01:57 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)
Under Appeal
Type A
10/04/2022
Section Cited
CCR
80036(e)

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Licensing Fees
The failure of an applicant or licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.

This facility was deficient as evidence by:
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Facility designated personnel stated that the annual license fees will be paid and a copy of the receipt will be scanned and emailed to this LPA. A statement of correction, along with a copy of the receipt, will be submitted by the due date of 10/04/2022.
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CCL records indicated that this facility license was effective on 08/25/2021 and a notice of payment was sent out to this facility on 06/01/2022. The due date for payment was 08/25/2022.
As of the date of this case management visit, 09/30/2022, this facility was still showing that the annual license fee had not been paid.
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Under Appeal
Type A
10/04/2022
Section Cited
CCR80087(a)

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Buildings and Grounds
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 facility was deficient as evidenced by:
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Facility designated personnel stated that a third party vendor, gardener, will be contracted to clean and remove all of the weeds and dried vegetation with stickers/burrs. A statement of correction, along with a copy of services rendered from the gardener and photos of the backyard, will be completed and submitted into CCL by the due date of 10/04/2022.
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A tour of the backyard area and space intended for resident use was overgrown with weeds and dried vegetation with stickers/burrs which prevented facility residents from going outside to enjoy this space.
This posed an immediate threat to the Health, Safety, and Personal Rights of the residents 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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