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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701271
Report Date: 10/20/2025
Date Signed: 10/20/2025 11:16:18 AM

Document Has Been Signed on 10/20/2025 11:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DREAM CARE #4FACILITY NUMBER:
502701271
ADMINISTRATOR/
DIRECTOR:		JAMES, IBONIFACILITY TYPE:
735
ADDRESS:2604 VERRANO AVETELEPHONE:
(510) 875-4894
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 3DATE:
10/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:33 AM
MET WITH:Nicolette Taylor TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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On 10/20/2025, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a Plan of Correction (POC) visit.. LPA was greeted by Staff Member (SM), Carlette Sharpe and explained the purpose of the visit. SM Sharpe notified the Facility Designated Representative (FDR), Nicolette Taylor that CCL was present. SM Sharpe notified LPA Pascua that FDR Taylor would be arriving shortly. LPA Pascua asked SM Taylor to contact the Facility Designated Administrator (FDA), Iboni James to inform them that CCL was present. It was learned that FDA James was unable to be reached during the time of this visit. There was one other staff member present, Carlette Sharpe.

Current census was 3. A brief interview with SM Taylor was conducted.

The purpose of this case management visit was in response to additional information learned during a complaint investigation delivered on 10/20/2025. Based on the investigation the following violations were learned: Personal rights, Personnel Requirements, False Statements, and Administrator Qualifications.

Based on interviews and a review of facility records, it was determined that on October 8, 2025, at approximately 5:00 AM, Resident 1 (R1) was found asleep in the facility’s backyard with a guest. Staff 2 (S2) discovered R1 and woke them by shining a phone light in their face. R1 responded by stating they did not want to get in trouble and would leave if necessary. S2 assured R1 they were not in trouble and allowed them to continue resting.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DREAM CARE #4
FACILITY NUMBER: 502701271
VISIT DATE: 10/20/2025
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Between 7:00 AM and 7:30 AM, Staff 1 (S1) reportedly woke R1 by yelling and cursing at R1 and their guest, demanding they leave. S1 threatened to physically assault the guest and continued to escalate the situation. During this altercation, R1 attempted to get up but S1 reportedly slapped the phone out of R1's hand, hitting R1’s wrist. R1 became visibly upset, entered the facility, and began destroying property while yelling at staff and repeating the threats made by S1.

According to R1’s Individual Program Plan (IPP) and behavioral documentation, R1 has a history of yelling at staff when provoked. Witnesses further stated that the altercation continued into the front yard, where S1 allegedly continued to verbally threaten R1, including threatening that their partner would harm R1 while S1 would assault the guest. During this time, witnesses observed S2 recording R1 on a phone while laughing. R1 confirmed that they slapped the phone from S2’s hand, prompting S2 to lunge at R1 with their hands raised as if to choke them, but S2 quickly retracted.

It was later revealed that R1 was not permitted to have their guest on the premises due to conflicts with a roommate. However, a temporary arrangement was not made to allow the visit.

During the incident, Staff 3 (S3) reportedly locked themselves in the facility office, expressing fear due to R1's behavior. Interviews with S3 and Staff 4 (S4) indicated they initially claimed to be unaware of the backyard incident and denied the presence of other staff. However, in interviews conducted by Licensing Program Analysts (LPAs) Pascua and Hughes on October 9, 2025, both SM3 and SM4 confirmed that S1 and S2 were present during the incident. Additionally, both acknowledged that R1 typically yells at staff when upset.

Video footage from the incident corroborated witness statements, showing S2 following R1 through the facility while laughing and filming. The footage also confirmed that multiple staff members were aware of and present during the incident.

In response, Valley Mountain Regional Center implemented an Immediate Danger Protocol, prohibiting S1 and S2 from entering or working in the facility until further notice. Facility Administrator and Licensee, Iboni James, was notified by phone and email of this restriction.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DREAM CARE #4
FACILITY NUMBER: 502701271
VISIT DATE: 10/20/2025
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On October 9, 2025, LPAs Pascua and Hughes conducted an unannounced visit. During this visit, LPA Pascua requested S4 to notify Facility Designated Administrator (FDA), Iboni James of their presence. Shortly after, S2 arrived at the facility. LPA Pascua informed S2 that they were prohibited from being on the premises. It was later revealed that FDA James had instructed S2 to be present due to CCL’s visit. When contacted, FDA James agreed to designate S4 to complete the visit.

Despite the immediate danger protocol which prohibited S1 and S2 from the facility, witnesses confirmed that S2 continued to be present at the facility on October 9, 11, 12, and 17, 2025, in direct violation of the Immediate Danger Protocol.

Based on the investigation, it has been determined that the licensee violated residents’ personal rights and failed to adhere to the Immediate Danger Protocol, resulting in significant health and safety concerns for residents.

Title 22 Section 80072(a)(1) and Section 80072(a)(3) were not cited during this case management visit due to being cited in a prior complaint visit on 10/20/2025.

As a result, the following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted and a copy of this report along with appeals rights were provided to the facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2025 11:16 AM - It Cannot Be Edited


Created By: Arielle Pascua On 10/20/2025 at 10:37 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE #4
FACILITY NUMBER: 502701271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/21/2025
Section Cited
CCR
80072(a)(2)

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(a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The facility will undergo training from a vendorized trainer for no less than (1) hour in duration on the topic of Resident Rights and Maintaining Personal Rights.
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This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that R1 was provided a safe, healthful, and comfortable accommodation. This poses an immediate health, safety, and personal rights risks to persons in care.
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A statement of correction and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.
Deficiency Dismissed
Type A
10/21/2025
Section Cited
CCR85072(b)(4)

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(b)The licensee shall insure that each client is accorded the following personal rights. (4) To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This is not met as evidenced by:
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The facility will undergo training from a vendorized trainer for no less than (1) hour in duration on the topic of Resident Rights and Maintaining Personal Rights.
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Based on interviews conducted, the licensee did not ensure that R1 had a right to a visitor. This poses an immediate health, safety, and personal rights risks to persons in care.
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A statement of correction and acknowledgement along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2025 11:16 AM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Arielle Pascua On 10/20/2025 at 10:40 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE #4
FACILITY NUMBER: 502701271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/21/2025
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This is not met as evidenced by:
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The administrator will conduct a Personal Requirement training session for no less than (1) hour for all facility staff emphasizing de-escalation techniques and procedures to ensure the health and safety of other staff and residents.
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Based on interviews conducted, the licensee did not ensure that facility staff were able to deescalate R1’s behavior. This poses an immediate health, safety, and personal rights risks to persons in care.
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A statement of correction, along with documented proof of scheduled training topics, dates, and times will be completed and submitted into CCL by the due date.
Request Denied
Type A
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Section Cited
CCR80012(a)

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(a)No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This is not met as evidenced by:
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A statement of correction and acknowledgement shall be sent to CCL by the POC date.
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Based on interviews and record review, the licensee did not ensure that facility staff had consistent statements regarding the incident on 10/08/2025. This poses an immediate, health, safety, and personal rights risks 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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2025 11:16 AM - It Cannot Be Edited


Created By: Arielle Pascua On 10/20/2025 at 10:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DREAM CARE #4
FACILITY NUMBER: 502701271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/21/2025
Section Cited
CCR
80064(a)(3)

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(a)The administrator shall have the following qualifications: (3)Knowledge of and ability to comply with applicable law and regulation. This is not met as evidenced by:
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Facility Administrator will review Administrator Qualifications and Duties regulation by POC date. Administrator a statement indication regulation was reviewed by POC date.
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Based on interview, records review, and observation, the Licensee did not ensure they followed the Immediate Danger Protocol implemented by Valley Mountain Regional Center. This poses an immediate, health, safety, and personal rights risks 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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2025


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