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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:11:59 PM

Document Has Been Signed on 06/29/2023 04:11 PM - 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:
06/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Norma Borgus TIME COMPLETED:
02:00 PM
NARRATIVE
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On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived to this facility unannounced to conduct a POC visit.

Upon arrival at the facility, at 1:45pm LPAs knocked on the door several times and no one answered the door. While calling the facility numbers, LPAs observed a resident peeking out the window twice and was asked to get staff to open the door. At 2:30pm, LPAs called two separate facility numbers and was unable to reach the facility at this time. The resident was observed to close the blinds and did not engage with the LPAs. LPAs continued to knock on the door for 10 minutes with no answer. LPAs called non-emergency to conduct a wellness check.

At 3:45pm, LPAs observed staff member enter the facility. At 3:45 and 4:00pm, LPA knocked on the facility door and was unable to obtain entrance.

An interview with Modesto Police Department was conducted, it was learned that staff has been directed by the Licensee that they cannot provide any information.

On 06/26/2023, Licensing Program Analysts (LPAs) Arielle Pascua, Christina Valerio and Arvin Villanueva arrived unannounced to this facility to conduct a complaint visit. LPAs were greeted by staff member (SM) Norma Borges and explained the purpose of the visit. LPA Pascua asked that SM Burgos contact the Facility Desingated Administrator (FDA) to inform them that CCL was present at this time. LPAs were informed that the FDA, Julian Hawes, was unable to come to the facility at this time due to other meetings. LPAs continued the visit with SM Borges. The purpose of this visit is to deliver complaint findings for the allegations above.
The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 06/16/2023 from a prior case management visit conducted on 06/15/2023.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/29/2023
NARRATIVE
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Based on the observations and interviews made during 06/26/2023 the following deficiencies were cited per the California Code of Regulations, Title 22 and Health and Safety Code.
  • An immediate civil penalty of $500 was assessed during this case management visit today, on 06/26/2023, for a violation of Section 80044(a)(2). The Facility Designated Administrator was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.
  • A civil penalty in the amount of $1,300 was assessed for violations of Section 80044(c) for the time between 06/17/2023-06/29/2023. This civil penalty was due to failure to correct the deficiency by the Plan of Correction date. The Facility was informed that the civil penalty will continue to accrue $100 per day per violation until the deficiency is corrected.

Exit interview was conducted and copy of the 809, 809D, and appeals rights were emailed to the Facility Designated Administrator at the end of the visit. An electronic response from FDA Hawes confirms receipt of this report.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 04:12 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/29/2023 at 01:29 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/30/2023
Section Cited
CCR
80044(a)(2)

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80044(a)(2) Inspection Authority of the Licensing Agency
(2) Health and Safety Code Section 1533 provides in part:
...any duly authorized officer, employee, or agent of the State Department of Social Services may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter.
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An immediate civil penalty is hereby issued on 06/29/2023 in the amount of $500.
Licensee agrees to send in a written statement of acknowledgement that he has read the cited section to it’s entirety to the LPA’s email at Arielle.pascua@dss.ca.gov by 06/30/2023 at 5pm.
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This requirement was not met as evidenced by:
Based on observation, LPAs were not able to obtain entrance to the facility at 1:40pm, 2:30pm, and 3:45pm. This poses an immediate health, safety, and personal rights risks to persons in care.
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Request Denied
Type A
06/30/2023
Section Cited
CCR85064(j)(3)

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85064
Adminstrator Qualifications and Duties
(j) The administrator shall perform the following duties:(3) Recruitment, employment and training of qualified staff, and termination of staff.
This is not met as evidenced by:
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Facility Administrator will conduct a review of the section, 85064(j)(3). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov
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Based on observation, LPAs were unable to obtain entrance to the facility. This poses an immediate health, safety, and personal rights risks to persons in care.
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LPA's email at Arielle.pascua@dss.ca.gov by 06/30/2023 at 5pm.
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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


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