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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 11/15/2024
Date Signed: 11/15/2024 12:09:31 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/15/2024 12:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DE TRIO HEALTH CAREFACILITY NUMBER:
392700516
ADMINISTRATOR/
DIRECTOR:		BONNER, WILLIAMFACILITY TYPE:
735
ADDRESS:905 W. MAGNOLIATELEPHONE:
(209) 475-8243
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 4CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:C. LockwoodTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived to conduct an unannounced annual inspection on this date. LPA met with Lockwood explained the purpose of the visit. Later joined by Denica Layne.

LPA inspected the physical plant including but not limited to the kitchen, resident bedrooms, resident bathrooms, laundry area, and backyard area. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers is in need of service. It was due for service on 10/25/2024. The smoke detectors and carbon monoxide detectors is operational. LPA observed unlocked medication belonging to a parent of one of the residents. Toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident and 2 staff file, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Fire drill was conducted on 10/3/2024.

Deficiencies were cited per Title XXII and CCL regulations.

Exit Interview
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/15/2024 12:09 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/15/2024 at 11:14 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DE TRIO HEALTH CARE
FACILITY NUMBER: 392700516

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2024
Section Cited
CCR
80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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Administrator shall have the fire extingushier serviced by close of business of POC date.
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This requirement is not met as evidenced by observation the Fire extinguishers is in need of service. It was due for service on 10/25/2024.
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Type A
11/16/2024
Section Cited
CCR80075(k)(1)

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80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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Plan of correction: Facility has locked medications and will notify the mother that the medication is at the facility and instructed staff of medication storage requirements. Facility will retrain staff and send CCL proof of training within 30 days.
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This requirement was not met as evidenced by: unlocked medication belonging to a parent of one of the residents was on the top of the dresser. This poses an immediate health and safety risk to clients in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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