502701271-8-12-2025-27-AS-APAA-DKGNXG-20250812105106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701271
Report Date: 08/12/2025
Date Signed: 08/12/2025 10:51:17 AM

Document Has Been Signed on 08/12/2025 10:51 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 #4		FACILITY NUMBER:	502701271
ADMINISTRATOR/ DIRECTOR:	JAMES, IBONI		FACILITY TYPE:	735
ADDRESS:	2604 VERRANO AVE		TELEPHONE:	(510) 875-4894
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 4		CENSUS: 4	DATE:	08/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Kenroy Anderson		TIME VISIT/ INSPECTION COMPLETED:	11:15 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	Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA was greeted by Staff Members, Nicolette Taylor and Carlette Sharpe and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. LPA asked the SM Taylor and SM Sharpe notify the Facility Designated Administrator (FDA), Iboni James, that CCL was present at this time. Shortly after, LPA Pascua was met by Facility Designated Representative (FDR), Kenroy Anderson. Current census was 4. 2 out 4 residents were in their respective rooms during this visit. 2 out 4 residents were out at the facility on outings at this time. This facility is licensed to serve residents who are 18 through 59 and may be ambulatory only. This facility may also serve and retain Level 7 residents and vendorized by Valley Mountain Regional Center. LPA reviewed 4 resident files and 4 staff files. All staff and resident files were complete and up to date. A tour of the facility was conducted. The administrator has a current and active administrator certificate #6066151735 and expires on 07/09/2027. A tour of the facility was conducted. Upon entry at the facility. It was observed that the facility had a new enclosed office space next to the living room. LPA Pascua inquired if the facility sketch was provided to the department to initiate a new fire clearance. FDR Anderson stated and provided LPA Pascua a new fire clearance that was approved for the enclosed office space on 07/18/2025 by Modesto Fire. In addition, a new facility sketch was provided to LPA Pascua. LPA Pascua advised that once any changes happen at the facility to inform the department to initiate a new fire clearance. 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.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

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.

LIC809 (FAS) - (09/23)

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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: 08/12/2025

NARRATIVE

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The fire extinguisher, located in the kitchen area, was services by a local fire extinguisher Company, Jorgenson Co on 06/16/2025 and is compliance at this time. All smoke detectors and carbon monoxide were present and working at this time. The last facility fire drill was conducted on 07/21/2025.
Medication was observed to be housed in the black cabinet located near the kitchen. It was learned that this facility has been utilizing an Electronic medication system, Caring Data. 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.
The following forms were requested to be updated:
-LIC 308
-LIC 400
-LIC 500
-LIC 610

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, no deficiencies were observed during today’s visit.

An exit interview was held, and a copy of the report was provided in-person.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

LIC809 (FAS) - (06/04)

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