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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701271
Report Date: 10/09/2025
Date Signed: 02/11/2026 10:47:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251008133423
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: 3DATE:
10/09/2025
UNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Nicolette Taylor TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared staff present at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report is being amended to generate a new LIC9099 to issue the citation under the correction regulation. The new LIC9099 dating on 02/11/2026, will supersede this LIC9099.
On 10/09/2025, Licensing Program Analysts (LPAs) Arielle Pascua and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Staff Members (SM), Nicolette Taylor and Carlette Sharpe and explained the purpose of the visit. LPA Pascua asked for SM Taylor to contact the Facility Designated Administrator (FDA), Iboni James that CCL was present. Shortly after, SM Kenroy Anderson arrived and left 5 minutes later. LPA Pascua spoke with FDA James who appointed SM Taylor as her representative in her absence.
Current census was 4. 2 out 4 residents were out of the facility at this time.
Based on interviews conducted, it was learned that S1 was present at the facility in the morning. In addition, interviews revealed that S1 is present at the facility often throughout the week. LPA Pascua reviewed the Licensing Information System and Guardian System and observed through review of these records that S1 was not associated to this facility. Based on the information gathered, there was an uncleared staff member present at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20251008133423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/09/2025
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
26
27
28
29
30
31
32
An immediate civil penalty of $500 was issued for violation of Section 80019(e)(2).
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20251008133423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/10/2025
Section Cited
CCR
80019(e)(2)
1
2
3
4
5
6
7
(2) Obtain a California clearance or a criminal record exemption as required by the Department or
This is not met as evidenced by: Based on interviews and record review the Licensee did not ensure that S1 had a criminal record clearance. This is an immediate health, safety, and personal rights risks to persons inc are.
1
2
3
4
5
6
7
Licensee shall provide a statement of correction and acknowledgement to this LPA by POC date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4