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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 04/14/2021
Date Signed: 04/14/2021 11:30:45 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2019 and conducted by Evaluator Praveen Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20190821093600
FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR:NEAL TORRESFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(510) 548-6600
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 77DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Erika Mendez, Wellness CoordinatorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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-Resident was illegally evicted
-Lack of supervision resulting in resident wandering away from facility multiple times
-Facility alarm system is not working
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Wellness Coordinator Erika Mendez to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference. During the investigation, LPA conducted interviews, made observations, and obtained documentation and information related to the allegations.

It was alleged that R1, who was admitted at the facility on 8/13/19, was illegally evicted from the facility on the evening of 8/20/19. Based on the investigation, R1 eloped from the facility and was found by the Antioch Police Department around 8:00 p.m. on 8/20/19. When R1’s responsible party (RP) arrived at the facility, it was decided by the facility to send R1 home with R1’s RP. During LPA interviews with staff, S1 stated per ED's direction, they felt it was best for R1 to go home with R1’s RP that night. The same was also indicated on facility charting notes for 8/20/19. Based on the evidence, facility failed to issue a proper eviction notice.

[See LIC9099-C for continuation of report]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 6
Control Number 15-AS-20190821093600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TREVISTA ANTIOCH
FACILITY NUMBER: 079200748
VISIT DATE: 04/14/2021
NARRATIVE
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It was also alleged that R1 wandered away from the facility multiple times due to lack of supervision. LPA reviewed records which indicated R1 wandered away constantly. A caregiver noted on 8/17/19, that R1 "wonders to the point a private caregiver is in need". In the span of R1's eight days in the facility’s Memory Care Unit, it was noted numerous times R1 wandered the halls into other residents’ rooms and on multiple occasions, R1 was found wandering on the third floor which is part of the facility’s Assisted Living area. On 8/20/19, R1 eloped from the facility and was found by the Antioch Police Department a few blocks away from the community. Charting notes on 8/20/19, indicated R1 was last seen by staff at around 7:00 p.m. and staff did not realize R1 was missing until the Antioch Police Department made contact at around 8:00 p.m. Resident pre-admission records indicate facility was aware R1 had wandering behaviors and even after observing R1’s excessive needs, failed to provide increased supervision.

It was also alleged that the facility’s alarm system for the Memory Care Unit exits were not working and/or construction workers propped doors open during construction projects. During LPA's walk-through of the facility on 8/23/19, LPA observed that in the Memory Care Unit on the second floor, there was a delayed egress door that allowed residents to go through a short hallway and into the enclosed outside area. In that same short hallway was a stairwell that went upstairs to the third floor where upon entry no alarms were set off. The third floor is an open area in the Assisted Living area which leads to the front entrance/exit. Per charting notes, R1 was found wandering on the third floor multiple times during R1’s stay.

Based on all the information gathered, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC9099-Ds.

Exit interview conducted and a copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2019 and conducted by Evaluator Praveen Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20190821093600

FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR:NEAL TORRESFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(510) 548-6600
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 77DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Erika Mendez, Wellness CoordinatorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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-Facility failed to notify responsible party of resident's disappearance
-Staff did not meet resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Wellness Coordinator Erika Mendez to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference. During the investigation, LPA conducted interviews, made observations, and obtained documentation and information related to the allegations.

It was alleged that the facility failed to notify R1’s RP when R1 went missing on 8/20/19. Based on interviews and records obtained, the facility was unaware of R1’s elopement until the Antioch Police Department informed them that R1 had been found. By the time the facility attempted to contact R1’s RP, R1’s RP already appeared at the facility after having been notified by the Police.


[See LIC9099-C for continuation of report]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20190821093600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TREVISTA ANTIOCH
FACILITY NUMBER: 079200748
VISIT DATE: 04/14/2021
NARRATIVE
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It was also alleged that staff did not meet resident's bathing needs. It is noted in the charting notes that R1's RP prefers for R1 to shower every day. It was alleged that R1 had not been given any showers during his stay at the facility. On R1's Needs and Services Plan, it is indicated that R1 will receive full assist with showers twice a week or as needed. During R1's stay at the facility from 8/13/19-8/20/19, it was noted by staff that R1 refused showers every day except on 8/18/19 where it's indicated that R1 had a shower that day.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20190821093600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TREVISTA ANTIOCH
FACILITY NUMBER: 079200748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited
CCR
87224(c)
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Eviction Procedures. (c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.
This requirement is not met as evidenced by:
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Licensee states an eviction policies and procedures will be established and training will be provided to all staff regarding proper eviction requirements. Licensee states a copy of facility eviction policies and training record will be sent to LPA Singh via email. Licensee will email LPA Singh a plan for excuting this POC by POC date.
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Licensee’s failure to issue a required eviction notice and notice to quit to R1’s responsible party (RP). On 8/20/19, R1’s RP was asked to take R1 back home with RP late in the evening without any prior notice or preparation, which poses an immediate health, safety, or personal rights risk to a person in care.
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Type A
04/15/2021
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Licensee states proper protocol will be established to ensure residents who require increased supervision get their needs met and/or to identify how to address appropriate level of care needs for residents. Licensee will send documented protocol to LPA Singh via email by POC date.
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This requirement is not met as evidenced by licensee’s failure to ensure adequate supervision was maintained to meet R1’s needs. Facility failed to address the need resulting in R1’s elopement which poses an immediate health, safety, or personal rights risk to a person 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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20190821093600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TREVISTA ANTIOCH
FACILITY NUMBER: 079200748
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2021
Section Cited
CCR
87705(j)
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Care of Persons with Dementia. (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by licensee’s failure for alert features that monitor Memory Care stairwell exits.
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Licensee states staff alert features for all stairwell exits/entrances will be installed. Proof of correction will be sent to LPA Singh via email by POC date.
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It was noted that staff found R1 repeatedly wandering the third floor. Based on LPA’s observation, the Memory Care Unit stairwell leading upstairs to the third floor Assisted Living area did not have a staff alert feature which poses a potential health, safety, or personal rights risk to a person 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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6