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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 09/18/2023
Date Signed: 09/20/2023 08:40:15 AM

Document Has Been Signed on 09/20/2023 08:40 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:NORMA BORGESFACILITY TYPE:
735
ADDRESS:408 FAIRWAY DRIVETELEPHONE:
(510) 320-2800
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 4DATE:
09/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Norma Borges TIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/18/2023, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA) Norma Borges and explained the purpose of the visit.
Current Census was 4. A brief interview was conducted with FDA Borges was conducted. There was one other staff member present at this facility at this time, Karen Marcos.

The purpose of this visit was to obtain documentation regarding S1.
It was learned during this visit that S1 was not associated at the time of the LPAs visit. LPAs asked for documentation to provide proof that S1 was associated. LPA Pascua was shown a letter to show S1's association but was not addressed to this facility. Upon review of Guardian it was observed that S1 was not associated until 12:44pm on 09/18/2023. It was stated that S1 started working as of today, however, based on review of the Medication Administration Record it was found that S1 has initialed for several medication administration records since 09/01/2023.

Deficiencies were observed during today’s visit. An immediate Civil Penalty has been issued for $500 for violation of 80019(e)(3). This civil penalty was due to S1 not being associated to the facility prior to working.

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 conducted and copy of this report was provided to the facility at the end of this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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 09/20/2023 08:40 AM - It Cannot Be Edited


Created By: Arielle Pascua On 09/18/2023 at 01:01 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: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/18/2023
Section Cited
CCR
80019(e)(3)

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Criminal Record Clearance. Individuals subject to criminal record reviews shall, prior to working, residing or volunteering in a licensed facility, request and be approved for a transfer of a criminal record exemption, unless, upon request for the transfer, the Department permits the individual to be employed, reside or
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An immediate civil penalty was assessed for $500.
This deficiency has been cleared during the visit. Licensee has transferred S1 to the facility via Guardian on 09/18/2023 at 12:48pm.
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 be present at the facility. LPA observed that there was a staff working at this facility that has a criminal record exemption and is associated to Dream Care, but is not associated to this care home, Dream Care 2. This poses an immediate health, safety, and personal rights risk for 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: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023


LIC809 (FAS) - (06/04)
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