<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701078
Report Date: 06/02/2023
Date Signed: 06/14/2023 11:59:35 AM

Document Has Been Signed on 06/14/2023 11:59 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:
06/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Norma Borgus TIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/02/2023 at 10:30am, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived unannounced to this facility to conduct a case management visit. LPAs were greeted by House Manager (HM) Norma Borgus and explained the purpose of the visit. LPAs asked that HM Borgus contact the Facility Designated Administrator (FDA) at this time to inform them that CCL was present. It was learned at this time that FDA Julian Hawes was unable to meet LPAs at the facility due to other meetings. LPAs continued the visit with HM Borgus. Current Census was 4. 1 out of 4 residents were out at their respective day programs.
The purpose of this case management visit is to follow up on documentation that was requested by department:

LPA Pascua requested the following documents:
  • Physician's report for R1
  • Needs/Services plan for R1
  • Admission record/Face sheet
  • Staff schedule for April 2023 with contact information
  • Resident roster

LPA Pascua requested that the following documents to be sent to the LPA's email at arielle.pascua@dss.ca.gov by 06/08/2023 at 5:00pm. Licensee was informed that failure to provide documentation may result in deficiencies.

No deficiencies cited during this case management visit. 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: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1