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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 08/08/2023
Date Signed: 08/09/2023 08:32:09 AM

Document Has Been Signed on 08/09/2023 08:32 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:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Norma Borges TIME COMPLETED:
02:00 PM
NARRATIVE
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On 08/08/2023, 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 Borges and explained the purpose of the visit. LPA Pascua asked that SM Borges call and informed Facility Designated Administrator (FDA), Julian Hawes, that CCL was present at the facility due to other obligations at this time. It was learned at this time that FDA Hawes was unable to come to the facility but LPA was able to speak with FDA Hawes on the phone. LPAs continued the visit with SM Borges.

Current Census was 4. A brief interview with SM Norma Borges was conducted.

The purpose of this visit was to follow up on a information that was received by the department has received an application for a change of ownership on 07/28/2023. Based on interviews conducted, it was learned that the facility did not notify the department, residents, and their responsible parties prior to the application being submitted.

Deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility staff Norma Borges. An exit interview was held, and a copy of the report was provided in-person and sent via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 08/09/2023 08:32 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/08/2023 at 11:02 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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
HSC
1562.15(b)(1)

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(b) (1) In addition to the notification requirements provided for in Section 1562.2, a licensee of an adult residential facility shall inform a resident and the resident’s representative, if any, of a proposed closure, including whether the licensee intends to sell the property or business, no later than 180 days before its proposed closure, or as soon as practicably possible.
This requirement was not as evidenced by:
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The Licensee stated that a letter of notice will be provided to the department, the residents, and their responsible parties by end of 08/11/2023. Licensee was also advised to notify Valley Mountain Regional Center.
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Based on interviews and record review, the licensee did not ensure residents and CCLD Licensing were given the proper notice of change of ownership, which poses a potential health and safety 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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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