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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502701474
Report Date: 01/28/2026
Date Signed: 01/28/2026 12:37:21 PM

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
12/04/2025 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251204163723
FACILITY NAME:DREAM CARE #1FACILITY NUMBER:
502701474
ADMINISTRATOR:MARTINEZ, DEBRAFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(510) 875-4894
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:4CENSUS: 4DATE:
01/28/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicolette Taylor TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee allowed excluded individual into the facility
INVESTIGATION FINDINGS:
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On 1/28/2026, Licensing Program Analysts (LPAs) Arielle Pascua and Jason Lund arrived unannounced to the facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA), Nicolette Taylor and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. There was one other staff member present, Venscott Smith.

Current census was 4. A brief interview with FDA Taylor was conducted.

It was alleged that the licensee allowed an excluded individual into the facility. During the course of this investigation, the department conducted interviews and reviewed facility records. Based on interviews conducted, it was revealed that S1 was witnessed and present at the facility during the week of 12/08/2025 after the Licensee and the facility was notified of the Immediate exlusion from the facility on 11/20/2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
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 3
Control Number 27-AS-20251204163723
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 #1
FACILITY NUMBER: 502701474
VISIT DATE: 01/28/2026
NARRATIVE
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Further review of facility records show that S1 signed the Medication Administration Record for 11/21/2025 and 11/22/2025 after the immediate exclusion of S1 was issued to the facility on 11/20/2025. Based on the information gathered, the licensee allowed excluded individual into the facility.

An immediate civil penalty of $500 was issued for Section HSC 1548 for allowing an excluded individual.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit along appeals rights.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251204163723
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 #1
FACILITY NUMBER: 502701474
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2026
Section Cited
HSC
1548(7)
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(7) The presence of a person subject to a department Order of Exclusion on the premises.
This is not met as evidenced by: Based on interview and record review, the licensee allowed an excluded individual on the premises of the facility after notification from the department on 11/20/2025. This poses an immediate health safety, and personal rights risks to persons in care.
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Licensee shall provide a statement of acknowledgement to the LPA by POC date.
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Type A
01/29/2026
Section Cited
CCR
80064(a)(3)
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(3) Knowledge of and ability to comply with applicable law and regulation.
This is not met as evidenced by: Based on interview and record review, the licensee did not comply with section cited above by allowing an excluded individual on the premises of the facility after an exclusion order was issued by the department.
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Licensee shall provide a written statement acknowledging the requirement to prohibit excluded individual from all facilities by the POC due date.
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 This poses an immediate health safety and personal rights risk 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3