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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200748
Report Date: 08/03/2020
Date Signed: 08/03/2020 02:28:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR:SONYA SMITHFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(925) 470-3395
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 94DATE:
08/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Becky Langdon, Regional DirectorTIME COMPLETED:
11:37 AM
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On 08/03/20 at 10:54 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Face time tele-visit with Regional Director (RD) Becky Langdon and Wellness Assistant (WA) Erika Mendez. LPA explained that the reason for the tele-visit was regarding an incident report submitted by the facility and received by LPA on July 30, 2020. Due to COVID-19 shelter in place order issued on March 17, 2020 by the Governor, Regional Director was not physically available to sign this report.

RD/WA informed LPA that on 7/28/20, resident (R1) told a family member that she was inappropriately touched by an agency caregiver on 7/27/20 at around 9PM at the facility. Per WA, this was an unwitnessed incident inside R1’s apartment. Staff called 911 and local police officer arrived at the community and spoke with R1. Facility requested agency caregiver not to come back to the facility while incident is being investigated by the police.

WA informed LPA that they have cross reported the incident to the LTCO, CCLD and local police department. WA informed LPA that agency caregiver has a criminal record clearance given to the facility by the third party caregiver agency prior to working at the facility. LPA explained to RD/WA that facility also needs to submit a criminal record transfer request to CCLD with a copy of a US issued current photo ID/License prior to start of work of each agency caregiver at the facility.

Deficiency cited for criminal record clearance under Advisory Notes (LIC 9102 - Technical Violation).

Exit interview conducted and a copy of this report provided to RD/WA via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
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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