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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700516
Report Date: 08/24/2021
Date Signed: 08/24/2021 05:09:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210820145241
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:
08/24/2021
UNANNOUNCEDTIME BEGAN:
03:57 PM
MET WITH:Royal Young, Licensee TIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff did not file special incident report in a timely manner
INVESTIGATION FINDINGS:
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On 8/24/21 at 3:57pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to open and investigate the complaint allegation listed above. LPA met with Royal Young, licensee and explained the purpose of the visit. During today's visit, LPA interviewed licensee who stated an incident report was faxed to regional center on 8-8-21 for an incident occurring on 8-1-21. LPA also interviewed Administrator during today's visit. LPA reviewed fax confirmation log which indicated a fax was sent to regional center on 8-8-21, but no confirmation to indicate a faxed incident report was sent to licensing agency within 7 days of occurrance. Additionally, there is no confirmation that report, verbal or written was made to licensing agency by department's next working day. LPA reviewed incident report for resident1 (R1) dated 8-1-21 and confirmed the incident report which indicated a threat to emotional health and safety of a client has not been received by licensing agency to date. Licensee faxed incident report to licensing department during today's LPA's visit. Based on record review and interview it is determined that an incident occurred on 8-1-21 and not reported to licensing department in a timely manner, therefore, this allegation is SUBSTANTIATED. An exit interview and a copy of this report and appeal rights was left with Licensee Royal Young.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210820145241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 392700516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited
CCR
80061(b)(E)
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Reporting requirements. (b)Upon the occurrence...of any of the events specified... below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified... below shall be submitted to...licensing agency within 7 days
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Licensee will submit a plan to ensure all incidents are reported timely to licensing agency as required. Plan to be submitted by POC due date.

Licensee will read regulation 80061 and submit as signed statement of understanding to LPA by POC due date.
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following the occurrence...(E) Any unusual incident...which threatens emotional health or safety of any client. This requirement is not met as evidenced by: Licensee did not ensure timely submittal of incident report to licensing agency for R1 which occurred on 8-1-21. This poses a potential health and safety risk to residents 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2