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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 09/01/2021
Date Signed: 09/01/2021 06:00:22 PM

Document Has Been Signed on 09/01/2021 06:00 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DE TRIO HEALTH CAREFACILITY NUMBER:
392700516
ADMINISTRATOR:BONNER, WILLIAMFACILITY TYPE:
735
ADDRESS:905 W. MAGNOLIATELEPHONE:
(209) 639-5134
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 4CENSUS: 4DATE:
09/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Denica Layne, Facility ManagerTIME COMPLETED:
05:17 PM
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On 9/1/21, at 3:05pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management for an incident which occurred on 8/30/21 and received at regional office on 8/31/21. LPA met with facility manager Denica Layne and explained the purpose of the visit. LPA spoke with Licensee William Bonner who gave permission for Denica Layne to sign in his absence. Incident report stated that Resident1 (R1) verbalized to regional center that a staff member grabbed his neck in an aggressive manner.

LPA requested the following documents including: Individualized Program Plan (IPP) R1, care staff notes, incident report, staffing roster, client roster, and physician notes.

LPA conducted interviews with Staff1 (S1) and S2, R1, R2, and R3. LPA reviewed IPP for R1. Facility manager was made aware that additional time is necessary to complete this case management. LPA will contact licensee at a later date for completion. No deficiencies cited as a result of today's visit.

An exit interview was conducted with Denica Layne and a copy of this report was left with Denica.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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