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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:01:11 PM

Document Has Been Signed on 10/07/2022 04:01 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: 3DATE:
10/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Leona HamiltonTIME COMPLETED:
04:16 PM
NARRATIVE
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On 10-7-22 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident report dated 9-11-22. LPA met with designated substitute staff Leona Hamilton and explained the purpose of the visit. Administrator William Bonner was made aware of LPA's visit and purpose. Facility manager was made aware of LPA's visit and purpose. LPA reviewed incident report with staff and conducted interview with facility manager via phone. Based on review of report and interview, it was determined that resident1 (R1) eloped from facility on 9-11-22 at approximately 5:00pm. Facility staff saw R1 walking up the street away from facility and attempted to verbally redirect him but without success, losing sight of R1. Staff continued to search for R1 and notified law enforcement at approximately 7:00pm At approximately, 8:43pm, it was reported that R1 returned home with a small scratch on wrist and dirt on body. According to report, R1 denied any harm caused by another individual in the community. Facility manager reported incident to licensing department, law enforcement, and R1's responsible person within regulatory time fame requirements.

Based on case management review, it was determined that staff were not aware of R1's general whereabouts from approximately 5:00pm to 8:43pm resulting in an absence of supervision.

Citation is issued as a result of today's case management. An immediate civil penalty in the amount of $500 is also issued to licensee due to absence of supervision on 9-11-22. An exit interview was conducted with Leona Hamilton and a copy of this report was left with Leona. Appeal rights explained and provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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 10/07/2022 04:01 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/07/2022 at 03:37 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: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2022
Section Cited
CCR
80078(a)

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Responsibility for providing care and supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee will read regulation 80078(a) and submit a signed declaration of understanding to LPA by POC due date.

Licensee to submit a plan to LPA describing new interventions in place to help ensure facility staff's knowledge of residents' general whereabouts.
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Based on interviews and record reviews, R1 eloped from facility on 9-11-22 and facility staff was unaware of R1's whereabouts resulting in an absence of supervision. This poses an immediate health and safety risk to residents in care. An immediate civil penalty of $500 is issued in addition to citation.
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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: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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