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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 12/29/2021
Date Signed: 12/29/2021 05:00:13 PM

Document Has Been Signed on 12/29/2021 05:00 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:
12/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Carli RagsdaleTIME COMPLETED:
05:05 PM
NARRATIVE
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On 12-29-21 at 3:23pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for a reported incident occurring on 12-2-21. LPA met with direct support professional Carli Ragsdale and explained the purpose of the visit. Facility manager Denica Layne was notified by phone and spoke with LPA regarding the purpose of the visit. Denica gave permission for Carli to sign in her absence. LPA also conducted facility tour and observed room temperature to be at 70*F. Facility was clean and sanitary with no foul odors. Sharp objects and toxins were inaccessible to clients in care. No obstructions to fire exits inside or outside observed by LPA. LPA reviewed incident report dated 12-2-21 with facility manager. Based on incident report it was reported that on 12-2-21 at 10:35am, facility received a phone call from Resident1 (R1) day program teacher stating R1 was removed from class due to inappropriate sexual remarks which also escalated into a fall involving both the teacher and R1 after R1 allegedly ran towards the teacher. It was also reported on incident report that R1 stated the teacher struck him causing a red mark to his lip. LPA reviewed R1s Individualized Program Plan (IPP) and interviewed facility manager. LPA also interviewed R1.

Based on interviews and record reviews, it was determined that this incident was reported to regional office on 12-3-21 and within 24 hours of incident occurrence. It was also determined through fax confirmation that incident was reported to ombudsman on 12-3-21 and within 24 hours of occurrence. It was further determined that facility did not report incident to local law enforcement within 24 hours of occurrence.

Deficiencies are cited today under Title 22, Division 6. An exit interview was conducted with Carli Ragsdale and a copy of this report was left with Carli. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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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Document Has Been Signed on 12/29/2021 05:00 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/29/2021 at 04:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DE TRIO HEALTH CARE
FACILITY NUMBER: 392700516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2022
Section Cited
CCR
80061(d)

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80061 Reporting Requirements. (d) Any suspected physical abuse that does not result in serious bodily injury of an...dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...This requirement is not met as evidenced by:
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Licensee will complete reporting requirements for the 12-2-21 incident by notifying corresponding local law enforcement and submit proof of reporting to LPA by POC due date.

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Based on interview and record review, Licensee did not ensure the reporting of a suspected physical abuse incident on 12-2-21 to local law enforcement within 24 hours of occurrence. This poses a potential health, safety, and resident rights risk to client in care.
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Licensee will read regulation 80061(d) and submit a signed statement of understanding to LPA by POC due date

Licensee will conduct staff training on regulation 80061 and submit proof of completed training to LPA by POC due date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2021


LIC809 (FAS) - (06/04)
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