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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:16:38 PM

Document Has Been Signed on 10/08/2021 04:16 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:
10/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Asiana FreemanTIME COMPLETED:
04:35 PM
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On 10-8-21 at 4:05pm Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to continue a case management regarding the allegation of staff physically abusing a resident opened by LPA on 9-1-21. LPA met with house lead caregiver Asiana Freeman and explained the purpose of the visit. LPA conducted interviews with Staff1 (S1) and S2 as well as interviews with Resident1 (R1), R2, and R3 on 9-1-21. Facility file documentation was also requested and collected on 9-1-21. On 9-2-21, the allegation of which this case management was based on was received by regional office as a complaint allegation and has been investigated.

Based on the information above the department has closed this case management. The findings for the allegation may be found by referencing complaint control number 27-AS-20210902144715.

No deficiencies are cited as a result of today’s visit.

An exit interview was conducted with house lead caregiver 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
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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