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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700516
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:00:31 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210902144715
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:
10/08/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Asiana FreemanTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Staff physically abused resident
INVESTIGATION FINDINGS:
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On 10-8-21 at 3:30pm Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver complaint findings for the allegation listed above. LPA met with house lead caregiver Asiana Freeman and explained the purpose of the visit. LPA spoke with Licensee Royal Young who gave permission for Asiana Freeman to sign in his absence. Throughout the course of this investigation LPA conducted interviews with Staff1 (S1), and S2 on 9-1-21 during a case management visit regarding this allegation. Additionally, on 9-1-21 interviews with Resident1 (R1), R2, and R3 were conducted. Interview with S4 was conducted on 10-5-21. Interview with Staff3 (S3) was conducted by LPA and Investigation Bureau (IB) on 9-27-21. Additional interview was conducted on 10-5-21 with a day program staff member. During this investigation, LPA also reviewed Individual Program Plan (IPP) and behavior assessment for alleged victim on 9-10-21 as well as a medical statement for alleged victim on 9-27-21, and the facility internal investigation on 10-5-21. Based on interviews conducted and records reviewed, it was revealed that alleged victim had visible linear marks on the neck area on 8-29-21 and described consistently by S1, S2, S3, and S4 as scratches..
{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 2
Control Number 27-AS-20210902144715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/08/2021
NARRATIVE
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It was further revealed through a medical statement review that alleged victim has a history of a skin condition

Additionally, based on interviews, it was revealed that alleged victim’s statements described an inconsistent timeline of events in which the alleged incident occurred including various dates of alleged occurrences; alleged victim stated during an interview that alleged incident occurred on 8-31-21, however, based on interview and record review it was determined that alleged perpetrator was not working at the facility on 8-31-21.
In addition, based on interviews, there were no statements of witnessed physical abuse towards alleged victim. Based on facility’s internal investigation reviewed, it was revealed that alleged victim was unable to recall when and where in the facility alleged incident occurred.
Interview with S4 and record review of alleged victim’s IPP and behavioral assessment revealed a history of alleged victim attempting to harm self and engage in other inappropriate behaviors including breaking windows, intentional rolling out of bed, and running into the street. IPP indicates a behavioral intervention plan for these behaviors

Based on the interviews and record reviews conducted during this investigation, it is determined that the above allegation does not meet the preponderance of evidence standard. Therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Asiana Freeman and a copy of this report was left with Asiana
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2