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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701271
Report Date: 08/25/2023
Date Signed: 08/27/2023 02:25:23 PM

Document Has Been Signed on 08/27/2023 02:25 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 #4FACILITY NUMBER:
502701271
ADMINISTRATOR:JAMES, IBONIFACILITY TYPE:
735
ADDRESS:2604 VERRANO AVETELEPHONE:
(510) 875-4894
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 0DATE:
08/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Iboni James TIME COMPLETED:
01:00 PM
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On 08/25/2023 at 11:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to the facility to conduct a Pre-Licensing visit. LPA Pascua met with Applicant, Iboni James. This facility will hold 4 residents who are deemed to be ambulatory only. This facility is awaiting vendorization from Valley Mountain Regional Center to serve and retain Level 4I residents.

Current Census was 0. A brief interview with Applicant was conducted.
The applicant has an administrator's certificate # 6066151735 and expires on 07/09/2025. First Aid and CPR was reviewed and is in compliance at this time.

A tour of the facility was conducted.

LPA toured the living room which will be used for a facility game room for residents in care. Furniture and furnishings were observed to be in good repair.
The fire extinguisher, located in the kitchen area, was purchased on 07/26/2023 and had a receipt attached to it at this time. All smoke detectors and carbon monoxide were present and working at this time.
The office area was toured and was observed to have all the required posters at this time.
A tour of the garage was conducted. LPA observed a locked cabinet which would hold resident and staff records. In addition, the facility will be holding medication in a locked cabinet located in the garage. This cabinet also hold knives, scissors, and additional cleaning supplies. A washer and dryer was identified in the garage.
The kitchen area was toured. Facility freezer and refrigerator showed to be functional and in compliance at this time. First aid kit was observed to be present and contained all of the required components at this time.
LPA observed a hallway closet, where additional linen was located. This hallway closet that was locked will also store additional cleaning supplies, laundry detergent, and other supplies.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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 2
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 #4
FACILITY NUMBER: 502701271
VISIT DATE: 08/25/2023
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A tour of the resident bathrooms were toured. Hot water temperatures were taken to ensure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.

A tour of 3 resident bedrooms was conducted. One resident bedroom is intended to be a shared bathroom and will have an adjoining private bathroom. All resident furniture and furnishings were observed to be in good repair.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and in compliance at this time.

Exterior grounds of this facility was toured. Perimeter fence and gates were checked and presented no hazards at this time.

This facility has been observed to be in compliance at this time.
There were no deficiencies observed during the course of this Pre-licensing visit.

Applicant has already conducted Comp I and Comp II.
Comp III was reviewed with applicant.

Exit Interview was conducted and a copy of this report was provided to the applicant.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
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