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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 01/27/2023
Date Signed: 01/27/2023 03:57:41 PM

Document Has Been Signed on 01/27/2023 03:57 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:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Denica LayneTIME COMPLETED:
02:30 PM
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On 1-27-23 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding incidents which occurred on 1-23-23 and 1-26-23. LPA met with assistant administrator Denica Layne and explained the purpose of the visit. Administrator William Bonner was made aware of LPA's visit and gave permission for Denica to accommodate LPA and sign in his absence.

On 1-23-22, an incident was reported involving resident1 (R1) and Staff1 (S1). According to incident report reviewed and interview with S1, R1 experienced a behavioral episode in which R1 struck staff and attempted to leave facility. S1 followed R1 outside the facility and attempted to redirect without success. S1 notified police who arrived and took R1 to local mental health facility and returned to facility same day after receiving medication at mental health facility. S1 submitted report to licensing department, and R1's responsible person within regulatory time frames. Licensee has updated needs and service plan to reflect new escalated behaviors.

On 1-26-23, an incident was reported involving resident1 (R1). According to incident report and interview with Administrator, R1 engaged in a behavioral episode in which R1 became agitated and hit staff in addition to yelling at staff. R1 also engaged in property destruction within facility. Additionally, R1 attempted to enter other residents room and throw feces at staff. Staff attempted to redirect R1 without success and notified police. R1 was taken to mental health on a 72-hour hold. An incident report was received by licensing within regulatory time frame. Additionally, R1's responsible party was notified. Licensee has updated needs and service plan to reflect new escalated behaviors.

As a result of today's case management, no citations are issued. An exit interview was conducted with Dencia Layne and a copy of this report was left with Dencia.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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