392700516-9-15-2021-27-AS-MBIR-C6VW2K-20210915165427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 09/15/2021
Date Signed: 09/15/2021 04:54:32 PM

Document Has Been Signed on 09/15/2021 04:54 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 CARE		FACILITY NUMBER:	392700516
ADMINISTRATOR:	BONNER, WILLIAM		FACILITY TYPE:	735
ADDRESS:	905 W. MAGNOLIA		TELEPHONE:	(209) 639-5134
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95203
CAPACITY: 4		CENSUS: 4	DATE:	09/15/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Denica Layne, Facility Manager		TIME COMPLETED:	04:55 PM

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On 9/15/21 at 3:25pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 9-12-21 at approximately 7:28am involving Resident1 (R1). LPA met with Denica Layne and explained the purpose of the visit. Denica Layne stated she had to take a client to a doctor's appointment and spoke with licensee who gave permission for caregiver Sylvia Warner to sign in her absence. LPA conducted interview with Denica Layne prior to her departure. Incident involved R1 engaging in physical aggression towards staff.

LPA conducted a case management inspection to ensure Title 22 compliance and health and safety concerns. All sharp objects and toxins were secured and inaccessible to clients in care. Room temperature was adequate at 75*F. There are no obstructions to fire exits inside or outside facility. There were 2 staff on duty during visit. LPA reviewed R1's Individualized Program Plan (IPP), physician’s report, facility care notes, and incident report dated 9-12-21. LPA also interviewed facility manager. Based on the interviews conducted and records reviewed it is determined that R1 has behavior interventions for verbal and physical outbursts in place as noted in the IPP dated 12/24/20 and behavior assessment dated 1/31/21. Facility manager stated she has arranged for psychiatric services for R1 which took place on 9/14/21 with a follow up appointment on 9/16/21 to address possible additional interventions.

{Cont on 809C)

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 392700516
	VISIT DATE: 09/15/2021

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Facility also conducted an internal investigation and determined that incident occurred due to a delay in R1 receiving food as well as one new staff on duty which may have created new stimulus for behavior. There were two staff total on duty during the incident. Incident prompted staff to call police due to physical damage to a staff member's car. Based on incident report reviewed, R1 was taken by police to behavior health center for services at approximately 11:30am and denied being a danger to himself and others. R1 was also able to identify triggers which caused him to attack staff and put himself in danger during the incident. Facility manager stated that when R1 returned home from behavioral health center, R1 had a staff assigned to monitor him for being a danger to self and others. Two staff members are scheduled during the day and night shift.

During today's visit, LPA observed R1 to be conversing with staff and other residents. R1 was observed to be laughing and engaging in calm dialogue, and not a danger to himself or others.

Based on the interviews, inspection, and documentation received and reviewed, the department has closed this case management and no further investigation is required.

Per California Code of Regulations, Title 22, Division 6 there were no deficiencies observed or cited during today's case management inspection. An exit interview was conducted with Sylvia Warner and a copy of this report was left with Sylvia.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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