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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700516
Report Date: 03/27/2024
Date Signed: 03/28/2024 10:08:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2024 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240225231211
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:
03/27/2024
UNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:D. Layne Operation Manager(OM)TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent a client from causing self harm
INVESTIGATION FINDINGS:
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On 3/27/2024, LPA Johnson arrived unannounced to deliver findings for the above allegation. LPA met with Demica Layne.

The allegation is substantiated, Based on the records reviewed and interview with the OM, the facility moved R1 in on a permanent bases on 2/6/24, prior to that R1 was at the facility for respite from 11/25/23 to 12/03/23. The facility is a behavior management home and is vendored through Valley Mountain Regional Center. The facility is required to have a behavior intervention plan for the residents in care. The plan should address the maladaptive behavior of each resident and provide guidance for the staff to help R1 or any other resident in care maintain their placement in a least restrictive environment.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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 3
Control Number 27-AS-20240225231211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DE TRIO HEALTH CARE
FACILITY NUMBER: 392700516
VISIT DATE: 03/27/2024
NARRATIVE
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Records reviewed confirmed that the facility does not have a 30 day assessment for R1 nor a behavior intervention plan. The information reviewed was a laminated 8'11" paper titled" Precursor Behavior Worksheet" and inconsistent data collection for all residents in care.

R1 has had multiple incidents and/or visits to the emergency room here is a list of the events: incident on 2/8/2024(medication error), ER visit 2/17/2024 (Admitted for vomiting blood and was discharged on 2/26/2024), incident 3/1/2024 (for aggression toward other consumer and staff), ER 3/4/2024 (Self injurious behavior) and ER 3/22/2024 (vomiting).

The discharge papers confirmed that R1 was to be seen by their primary care physician and/or other doctors for follow-up after the ER visits. The facility does not have follow-up information from any of the discharges for February or March.

R1 has multiple deliberate self harm scars from a history of self injurious behaviors and on today's visit, R1 had fresh skin breaks that caused bleeding on his hands, in his mouth around the teeth and gums. R1 has missed medications and is not eating regularly.

The facility staff is missing required training for each residents as it pertains to updated intervention plans and daily (consistent) behavior documentation for each resident.

As a result of this investigation the department finds this allegation to be SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240225231211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DE TRIO HEALTH CARE
FACILITY NUMBER: 392700516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
CCR
85064(j)(1,3)
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(j) The administrator shall perform the following duties:

(1) Where applicable, advise the licensee on the operation of the facility and advise the licensee on developments in the field of care and supervision.(3) Recruitment, employment and training of qualified staff, and termination of staff. This requirement is not met as evidenced by
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The Licensee will have R1's 30 day assessment completed and training for staff on the information complied by the Behaviorist. The plan will be sent to licensing by 3/28/2024 or the expected date for when the plan will be
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The lack of intervention plans for R1, not following-up on after ER visits and missing documentation for assessing or tallying R1's behaviors. This is an immediate health and safety risk to residents in care.
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sent to the department by 3/28/2024.
The licensee will submit an updated. An updated LIC 500 with the times and days when the Administrator will actually be at the facility. This information will be submitted by via fax or email on 3/28/2024 by close of business
Type B
04/05/2024
Section Cited
CCR
85068.4(a)(3)
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85068.4 Acceptance and Retention Limitations (a) The licensee shall not accept or retain the following: (3) Persons who have needs that are in conflict with the needs of other clients or the program of services offered.
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The facility will reassess R1 and determine if R1 is compatible with the other residents in the facility.

The facility will have an emergency meeting with the planning team and determine if R1 needs a higher level of care.
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This requirement is not met as evidenced by R1's continued required staff attention, aggressive actions towards other residents and intervention requirements to keep R1 and others safe.
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IE..Enhanced behavioral support or a step down facility. The facility will inform the department of the reassess by POC date 4/5/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3