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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701435
Report Date: 12/02/2024
Date Signed: 12/11/2024 10:52:39 AM

Document Has Been Signed on 12/11/2024 10:52 AM - 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 FOUNDATIONFACILITY NUMBER:
392701435
ADMINISTRATOR/
DIRECTOR:		BONNER JR, WILLIAM AFACILITY TYPE:
735
ADDRESS:401 W. POPLAR STTELEPHONE:
(209) 639-5134
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 4CENSUS: 0DATE:
12/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Royal Young and William Bonner JRTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Albert Johnson arrived announced to conduct Pre Licensing visit. LPA met with Royal Young and William Bonner JR. This facility will be vendor with Valley Mountain Regional Center for a Level 4 -I. This building has two stories.

LPA toured the facility inside and outside the facility making a Health and safety inspection. This facility was cleared for 4- ambulatory. Thermometers was place in the freezer and refrigerator. No dish washer in the kitchen. LPA observed pots, pans, cup, dishes and utensils.

Bathroom had night light and hot water tested at 110 degrees Fahrenheit. Four bedrooms for each residents. Master bathroom has a bathroom. Medication will be located in the dining room cabinet. First Aid Kit and Manual will be located in same dining area along with flash light.

Staff will be awake 24/7. LPA observed Fire Extinguisher inspected and Carbon Monoxide in the main hallway. Telephone(209) 475-8614 in the living room area. LPA observed table top games available. Outside : Building has over hang roof. Outside furniture and chairs provide. Separate Garage will be locked.

Component 3 waived.

This facility has meet Title 22 requirements at this time. The facility needs to complete advisories by 12/ 9/2024
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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