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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701271
Report Date: 08/26/2024
Date Signed: 08/27/2024 07:01:24 AM

Document Has Been Signed on 08/27/2024 07:01 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:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kenroy Anderson TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 08/26/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Director Support Professional (DSP), Nicolette Taylor and explained the purpose of this visit. LPA asked that DSP Taylor call the Facility Designated Administrator (FDA) Iboni James that CCL was present. It was learned that FDA James was unable to come to the facility at this time. However, LPA met with Facility Designated Representative (FDR), Kenroy Anderson and explained the purpose of this visit. The purpose of this visit was to conduct an annual visit. There was one other staff member present, Collette Sharpe.

Current census was 3. 2 residents were observed to be in the dining room eating breakfast. 1 resident was observed to be in their room during the course of this visit. This facility is licensed to serve residents who are 18 through 59 and may be ambulatory only. This facility may also serve and retain 4I residents and vendorized by Valley Mountain Regional Center.

LPA reviewed 3 resident files. The following was observed during record review:
-R1's file has another facility on record for their ID/Emergency contact sheet, release of medical information, needs and services plan, functional capability, telecommunication, and personal rights. R1 does not have an admission agreement for this facility.
-R2's file does not have a resident signature and is incomplete for the release of medical information. This resident does not have a needs and services plan completed.
-R3's file does not have a pre-appraisal and needs and services plan conducted. This resident also does not have an IPP on file.
LPA reviewed missing information with FDR Anderson.

LPA reviewed 4 staff files. 4 out 4 staff files did not have corresponding paperwork to this facility. LPA discussed that all paperwork shall be transferred over to this facility under it's respective name, Dream Care #4. LPA was able to confirm that all staff are background cleared and have active First Aid Certificates.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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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: 08/26/2024
NARRATIVE
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The administrator has a current and active administrator certificate #6066151735 and expires on 07/09/2025.
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. LPA did not observe a current fire extinguisher on facility premises at this time. All smoke detectors and carbon monoxide were present and working at this time.
LPA observed white cabinet in kitchen, it was observed that this was a murphy bed. It was stated that it was not used and will be used during break time. LPA reminded staff that the facility does not have a current staff room and a common area may not be used as a break area for staff to rest.
Medication was observed to be housed in the black cabinet located near the kitchen. It was learned that this facility has been ultlizing an Electronic medication system. Along with FDR Anderson, resident medication was reviewed and compared to Electronic medication logs. First aid kit was present and contained all the required components.
A tour of the garage was conducted. LPA observed a locked cabinet. This cabinet also hold knives, scissors, and additional cleaning supplies. A washer and dryer was identified in the garage.
LPA conducted a tour of the kitchen. LPA observed a sufficient amount of 2 day perishable and 7-day non perishable food supply. Knives were observed to be locked and made inaccessible.
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.
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 has an adjoining private bathroom. All resident furniture and furnishings were observed to be in good repair.
Exterior grounds of this facility was toured. Perimeter fence and gates were checked and presented no hazards at this time.
An immediate civil penalty of $500.00 is being accessed today for Section 80020(a).
Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility staff Kenroy Anderson. An exit interview was held, and a copy of the report was provided in-person.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/27/2024 07:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/26/2024 at 11:24 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not ensure that the Fire Extinguisher has been serviced within the last year. LPA observed that this fire extinguisher located in the kitchen had a receipt attached with the date of purchase on 07/26/2023. This poses an immediate health, safety, and personal rights risks to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Facility shall purchase a new fire extinguisher by the end of day and provide receipt of purchase to the LPA's email by 08/26/2024 at 5:00pm. In addition, a statement of correction and acknowledgement shall be provided to the LPA the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 07:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/26/2024 at 11:32 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85987(a)(3)

(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not ensuring that there was a private space for staff breaks. LPA observed a murphy bed in the dining area in the kitchen. It was stated that it has not been used, however, was supposed to be placed in the living room. This poses a potential health, safety, and personal rights risks to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee shall remove murphy bed from common area and provide proof of remove, such as a picture to the LPA by POC date. Licensee shall also provide statement of acknowledgement to this LPA by POC date.
Type B
Section Cited
CCR
85966(a)
(a) In addition to Section 80066, the following shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring that 4 out 4 staff records had corresponding paperwork to this facility. LPA observed that 4 out 4 staff records had information pertaining to a facility located on 408 Fairway Drive, Modesto. CA. This poses a potential health, safety and personal rights risks to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee shall provide a statement of correction and acknowledgment to the LPA by the POC date at 5:00pm.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/27/2024 07:01 AM - It Cannot Be Edited


Created By: Arielle Pascua On 08/26/2024 at 11:38 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85070(a)
(a) In addition to Section 80070, each client record must contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee did not comply with the section cited above in not ensuring that 3 out 3 resident files were complete and up to date. This poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee shall provide a statement of correction and acknowlegement to this LPA by the POC date at 5:00pm.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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