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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700516
Report Date: 08/30/2024
Date Signed: 09/17/2024 12:13:19 PM

Document Has Been Signed on 09/17/2024 12:13 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) 639-5134
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 4CENSUS: 4DATE:
08/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:04 AM
MET WITH:Cynthia LockwoodTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 8/30/2024, Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check. LPA met with Staff Lockwood.

Health and Safety check included overall safety of the facility including Staffing, health of residents, building and grounds

The LPA toured the physical plant to ensure the health and safety of residents in care. LPA reviewed copies of documents requested during the informal meeting on 8/14/2024. During today's inspection, LPA was made aware that R1 is still in the hospital (Admitted on 8/17/2024) to have medications adjusted. The facility does not have any additional information regarding R1's discharge date.

The facility is in compliance with the requested information. The department will continue to monitor the facility


Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
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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