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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 06/15/2023
Date Signed: 06/23/2023 09:08:57 AM

Document Has Been Signed on 06/23/2023 09:08 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:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Norma BorgusTIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/15/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a case management visit. LPAs were greeted by staff member (SM), Norma Borgus and explained the purpose of the visit. LPA Pascua asked for SM Borgus to go ahead and call the Facility Designated Administrator (FDA), Julian Hawes to inform him that CCL was present. It was at this time that LPAs learned that FDA Hawes was unable to come to the facility. LPAs continued the visit with SM Borgus.

Current Census was 4. A brief interview with SM Borgus was conducted.

The purpose of this visit is to follow up on the documentation that was requested by the department on a previous case management visit on 06/02/2023 and was due to LPA Pascua's email on 06/08/2023. As of the date of this visit, 06/15/2023, the department has not received documentation.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report was provided to the facility via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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 06/23/2023 09:08 AM - It Cannot Be Edited


Created By: Arielle Pascua On 06/15/2023 at 10:50 AM
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: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/16/2023
Section Cited
CCR
80044(c)

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80044 Inspection Authority
(c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d).
This is not met as evidenced by:
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The facility will provide complete documentation to the LPA by 06/16/2023 at 5:00pm. In addition, Licensee agrees to send in a written statement of acknowledgement that he has read the cited section 80044(c) to it’s entirety by the POC due date.
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Based on interviews and observations the facility did not ensure that documentation that was requested by the department was provided to the audits department and the LPA by due date on 06/08/2023. This poses an immediate health, safety, and personal rights risk to the 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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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