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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 10/05/2022
Date Signed: 10/21/2022 01:30:15 PM

Document Has Been Signed on 10/21/2022 01:30 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:
10/05/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Julian Hawes and Norma BorgesTIME COMPLETED:
01:30 PM
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Unannounced plan of correction visit made out to this facility on 10/05/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the facility caregiver, Norma Borges, who was requested by the LPAs to go ahead and contact the facility designated Administrator to inform him that CCL was present at this time. Facility staff Norma Borges went ahead and contacted the facility designated Administrator over the phone.
Current census was 4 residents of which 2 were out of the facility at this time at their respectable day programs.
The purpose of this visit was to follow up on the prior deficiencies and plan of corrections that were due on 10/04/2022 from a prior case management visit that was conducted on 09/30/2022.
Brief conversation was conducted with the facility designated Administrator Julian Hawes.
Due to pending time constraints since facility residents were slated to leave the facility premises and all facility staff were accompanying them, this visit had to be cut short.
As a result, it was agreed upon by the facility designated Administrator Julian Hawes that a copy of this plan of correction visit, and all accompanying documents, would be scanned and emailed to the facility designated Administrator Julian Hawes so as to not delay the residents any further.

As of the date of this visit, 10/05/2022, this LPA had not received any forms or documents to support that the plan of correction had been completed by this facility and its designated Administrator at this time.

This facility has been given a civil penalty in the amount of $200, per the following LIC 421FC documents, which will be ongoing until the plan of correction has been met.

Appeal rights were printed and a copy will be scanned to the email address of the facility designated Administrator Julian Hawes. Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2022
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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