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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701474
Report Date: 06/04/2026
Date Signed: 06/04/2026 12:13:36 PM

Document Has Been Signed on 06/04/2026 12:13 PM - 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 #1FACILITY NUMBER:
502701474
ADMINISTRATOR/
DIRECTOR:		NICOLETTE TAYLORFACILITY TYPE:
735
ADDRESS:2004 KRUGER DRIVETELEPHONE:
(209) 661-4666
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
06/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nicolette Taylor TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 06/04/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by Staff Member (SM), Colin Falconer and Vanscott Smith. LPA Pascua asked that they call the Facility Designated Administrator (FDA), Nicolette Taylor and inform them that CCL was present.
Shortly after, LPA Pascua met with FDA Taylor.
Current census was 4. it was learned that 2 out 4 residents were out at their respective day program at this time. 2 residents were observed in their rooms at the time of the visit. At approximately 10:00am, the facility power turned off at the facility. Facility staff checked on 2 residents in care. LPA Pascua obtained the facilities emergency disaster plan on site and identified that the facility did not have a generator on site. This plan was reviewed by FDA Taylor in April 2026. LPA Pascua also asked the facility administrator to contact the local power company, Modesto Irrigation District (MID), to inquire to why the facility power was off. At approximately 10:16am, the facility power was back on. LPA Pascua asked why the power went off, however it was unknown at this time.
A brief interview with FDA Taylor was conducted. 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 6 residents and vendorized by Valley Mountain Regional Center.
LPA reviewed 4 resident files and 5 staff files. All staff and resident files were complete and up to date. The facility administrator has an active administrator certificate, #6075135735 and expires on 10/11/2027. LPA Pascua reviewed the fire drill and disaster log, it was learned that the facility conducts weekly Fire Drills. The last fire drill was conducted on 06/01/2026, stating that all residents were present along with 2 staff on 9:13am. An emergency drill was conducted on 05/01/2026. The fire extinguisher was serviced by Jorgenson Co on 06/03/2026 and is in compliance at this time.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Arielle Pascua
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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 #1
FACILITY NUMBER: 502701474
VISIT DATE: 06/04/2026
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LPA observed a locked centralized stored medication cabinet located in the living room. Along with the administrator, the LPA observed, reviewed, and compared resident medication and electronic medication dispensing logs.
A tour of the facility was conducted.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply to meet the residents needs. Knives were observed to be locked and made inaccessible to the residents in care. A tour of the pantry was conducted where the facility holds extra non-perishable food supply.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
A tour of the garage was conducted. Additional food supply was identified.
A tour of the laundry room was conducted, laundry detergent, bleach and all other cleaning supplies were made inaccessible to the residents at this time.
The tour of 3 resident bedrooms were conducted. Furniture and furnishings were observed to be in good repair at this time.
A tour of the bathrooms was conducted. Hot water temperature was taken in 2 bathrooms. Hot water temperature in bathroom 1 was measured to be at 99.3 degrees. Hot water temperature in bathroom 2 was measured to be in 100 degrees. LPA Pascua reviewed the water temperature log and it was learned that on when water temperature was taken on 05/25/2026, the water temperature was measured at 100.3 and 102.4 in bathroom 1 and 102.4 and 100.5. in bathroom #2.
The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be in good repair at this time.
The following forms were requested to be updated and submitted to this LPA for review by 06/11/2026:
-LIC 308
-LIC 400
-LIC 500
-LIC 610
-A copy of the electricity and water bills for January 2026-Current
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 administrator, Nicolette Taylor. 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: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 12:13 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/04/2026 at 11:46 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 #1
FACILITY NUMBER: 502701474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 ensure that the hot water in the bathroom faucets were automatically regulated to deliver hot water no less than between 105 degrees F and no more than 120 degrees F. LPA Pascua tested hot water temperature during this visit and observed that hot water temperature in bathroom #1 was at 99.3 Degrees F and Bathroom #2 at 100.0 Degrees F. LPA Pascua also reviewed the facilities water temperature log which showed that both bathrooms dispensed water under 105 Degree F on 05/25/2026, and 06/01/2026. This poses a potential health, safety, and personal rights risks to persons in care.
POC Due Date: 06/19/2026
Plan of Correction
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Administrator states that the water heater will be adjusted to ensure that water temperature is dispensed automatically between 105-120 degrees. Administrator will also send updated water temperature logs by 06/19/2026 to LPA Pascua verifying the water temperature has been remedied. A picture of the water temperatures for 06/08/2026 and 06/15/2026 will also be sent to LPA Pascua to verify the water temperature reflects what is stated in the water temperature log.
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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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