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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701600
Report Date: 05/19/2025
Date Signed: 05/19/2025 01:04:17 PM

Document Has Been Signed on 05/19/2025 01:04 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 #3FACILITY NUMBER:
502701600
ADMINISTRATOR/
DIRECTOR:		JAMES, IBONIFACILITY TYPE:
735
ADDRESS:233 SUNSET BLVDTELEPHONE:
(510) 875-4894
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 4CENSUS: 0DATE:
05/19/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Iboni James, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an announced pre-licensing visit to this facility on 05/19/2025 at 10:00 am and was met by the Administrator/Applicant Iboni James. The facility is a two story facility licensed to serve up to 4 ambulatory clients. There were no clients present during today's pre-licensing visit. The first floor contains a bathroom/laundry room, gaming room with a foos ball/pool table, living room, kitchen and dining room. The outdoor area contains two seating areas, one of which is shaded. In the kitchen, LPA Campbell observed menus on the wall and refrigerator. The freezer meets the temperature requirements of zero degrees Fahrenheit (F) (17.7 degrees C) and the refrigerator temperature maximum of 45 degrees F (7.2 degrees C). Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. 

There are three entrances to the backyard from the back of the facility. The pathways to the emergency exit to the street were clear and free of obstructions. A tour of the facility was conducted.  Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.

Facility documents were displayed on the facility wall and included the: Administrator Certificate (7030637735, Exp 07/07/2027), Statement of Purpose, See Something, Say
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
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 #3
FACILITY NUMBER: 502701600
VISIT DATE: 05/19/2025
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Something poster, Personnel Report, Activity Calendar and Rights of Individuals with Developmental Disabilities. Cleaning products were stored in a closet with a coded lock with a key. LPA Campbell observed, cleaning products, tools and hygiene products as well.

Fully charged fire extinguishers were observed near the front door with a receipt with a purchase date of 05/18/2025. Facility sketches with emergency exits were posted in appropriate locations.  Medication was locked in a utility cabinet along with staff and resident files in the garage. The garage will be locked and inaccessible to residents. The first aid kit was observed in the living room and contained all required components at this time well as the manual, thermometer, tweezer and scissors.

A tour of resident bedrooms was conducted.  Furnishings and furniture intended for use by the clients was observed, along with mattress covers and linens that were found be sufficient and able to meet the needs of the clients at this time.  A tour of the resident bathrooms was conducted.  Hot water temperatures were taken and measured at 120 degrees Fahrenheit which is within the allowed range of 105-120 degrees.

A tour of the exterior grounds was conducted.  A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. There is a waist high side gate in the back that connects to the home next door at 235 Sunset Blvd. The licensee states they are open to raising the height of this gate if needed.

LPA Campbell has no objections to licensure. This prelicensing inspection has been passed. An exit interview was conducted and a copy of this report was left with Iboni James

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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