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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 08/11/2023
Date Signed: 08/11/2023 01:10:33 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, 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
06/21/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220621120143
FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR:ALBERTO MALDONADOFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(925) 470-3395
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 115DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident’s room is unsanitary
Resident’s hygiene needs are not being met
INVESTIGATION FINDINGS:
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On 08/11/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver the findings of above allegations. LPA explained the purpose of the visit with ED.

Allegation: Resident’s room is unsanitary
Investigation Finding: Substantiated
During investigation, witness (W1) stated she visited resident (R1) at the facility on several dates (11/30/21, 12/01/21, 01/22/22, 02/12/22, 05/01/22). On 06/21/22, LPA reviewed photos of R1’s room which showed fecal stains on R1’s toilet stand, bedroom wall, chair, rug, floors, sheets, light fixture, unflushed fecal matter inside the toilet and R1’s soiled pajamas and underwear. Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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 7
Control Number 15-AS-20220621120143
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: 08/11/2023
NARRATIVE
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Allegation: Resident’s room is unsanitary
Investigation Finding: Substantiated
Continuation...
W1 stated she reported these conditions to executive director (ED) who stated he would handle with staff. W1 visited R1 again on 12/01/21 with the bathroom in the same unsanitary condition, stained rugs not removed and washed. On 01/22/22, W1 visited R1 and found poop on the toilet and pajamas full of poop thrown in the shower. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that resident’s room is unsanitary was found to be substantiated.

Allegation: Resident’s hygiene needs are not being met
Investigation Finding: Substantiated
During investigation, witness (W1) stated family visited resident (R1) at the facility on several dates (11/30/21, 12/06,21) and reported to staff that R1 had not had a shower with hair greasy. W1 stated R1 was finally showered by staff on 12/07/21. W1 stated that from 12/10/21 until 12/13/21, R1 was again not given a shower. ED stated a care conference was held with W1 and R1’s family on 12/15/21. R1’s shower schedule was discussed as well as R1’s weight loss and meal menu. W1 stated staff showered R1 on 01/06/22. Review of R1’s care plan showed R1 required full assistance with weekly showering, wash, shampoo and dressing/undressing to maintain good personal hygiene and cleanliness. On 02/12/22, W1 stated she visited R1 and found her hair greasy again, she had no underwear on and was full of poop. W1 stated the bathroom floor had dried poop and asked staff to clean the room asap. Rather than wait for staff to show up, W1 and W2 stated they gave R1 a shower, washed her hair and placed clean underwear on her and fresh clothes.

Continued on next page, LIC 9099-C

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20220621120143
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: 08/11/2023
NARRATIVE
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Allegation: Resident’s hygiene needs are not being met
Investigation Finding: Substantiated
Continuation...
LPA reviewed photos on 06/21/22 which showed R1 with matted, greasy hair, underwear full of fecal matter, dried fecal stains on wall, chair and rug. Review of R1’s care plan showed staff will assist resident to set up toothbrush and toothpaste for oral care at least 2X per day with occasional reminders/cues with using toothbrush/toothpaste/floss or denture maintenance. LPA reviewed a photo of R1’s dental decay when R1’s family took her to the dentist for dental cleaning on 05/23/22. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that resident’s hygiene needs are not being met was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20220621120143
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: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
87303(a)(1)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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By POC due date, ED agreed to complete and submit to CCL in-service staff retraining certifications on the timely cleaning, sanitation and handling of residents’ dirty personal belongings in compliance with Title 22 Section 87303 regulations.
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This requirement was not met as evidenced by resident’s unsanitary room which posed a potential health & safety risk to resident in care.
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Type B
09/08/2023
Section Cited
CCR
87465(a)(1)
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A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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By POC due date, ED agreed to complete and submit to CCL in-service staff retraining certifications on providing residents with routine assistance in medical and dental care in compliance with Title 22 Section 87465 regulations.
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This requirement was not met as evidenced by resident’s hygiene needs not being met which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
06/21/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220621120143

FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR:ALBERTO MALDONADOFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(925) 470-3395
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 115DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Alberto Maldonado, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff failed to provide adequate care and supervision, resulting in resident sustaining significant weight loss
Facility is providing inadequate food service
Resident’s laundry needs are not being met
Facility restroom is in disrepair
INVESTIGATION FINDINGS:
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On 08/11/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver the findings of above allegations. LPA explained the purpose of the visit with ED.

Allegation: Facility staff failed to provide adequate care and supervision, resulting in resident sustaining significant weight loss
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed R1’s admission agreement which showed R1 moved into the facility on 11/26/21. R1’s physician report dated 11/09/2021 show her weight at 111 lbs. Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20220621120143
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: 08/11/2023
NARRATIVE
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Allegation: Facility staff failed to provide adequate care and supervision, resulting in resident sustaining significant weight loss
Investigation Finding: Unsubstantiated
Continuation...
LPA reviewed R1’s care plans which showed her weight in January 2022 at 99.8 pounds and 87.2 pounds in May 2022. W1 stated R1’s weight was at 80.6 pounds. LPA observed R1’s medication records showed R1’s primary care physician prescribed R1 to drink ensure nutritional shakes twice daily with a start date of 02/10/2022. Review of R1’s care plan dated 03/28/22 show a care conference was held by staff and her medical provider to address R1’s weight loss and lab work was ordered. Staff stated R1 refused to eat lunch and dinner due to poor appetite. Review of R1’s care plan dated 06/22/22 show staff provided R1 with nutritional shakes ordered by the doctor daily at 8AM, 12PM, 5PM. Staff stated R1 also had snacks twice daily. Based on interviews and record reviews which were conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff failed to provide adequate care and supervision resulting in resident sustaining significant weight loss is unsubstantiated.

Allegation: Facility is providing inadequate food service
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ED, S1) who stated that they implemented resident’s (R1) care plan which was full assist with special diet, providing a nutritional shake ordered by the doctor daily at 8AM, 12PM, 5PM and as needed. Staff (ED, S1) stated R1 does not eat much and refuses to drink all flavors of ensure nutritional shakes because she dislikes the taste. Staff stated they provided R1 with food that she likes such as egg, fruit, dessert. R1 also had snacks twice daily. Staff stated that despite their efforts, R1 continued to lose weight due to poor appetite. Staff (S1) stated they are cutting R1’s food at each meal and assisting her with setting up her food while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility is providing inadequate food service is unsubstantiated. Continuation on next page, LIC 9099-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20220621120143
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: 08/11/2023
NARRATIVE
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Allegation: Resident’s laundry needs are not being met
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed housekeeping schedules which showed weekly laundry was provided by staff to all 24 memory care residents to keep all clothing and linens clean. Staff (ED) stated each residents’ clothing, beddings, linens and towels were kept in dedicated laundry baskets that were laundered and delivered back by staff weekly. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident’s laundry needs are not being met is unsubstantiated.

Allegation: Facility restroom is in disrepair


Investigation Finding: Unsubstantiated
During investigation, staff (ED) stated that on 05/01/22, the common hallway restroom toilet was reported clogged. LPA confirmed with staff (S2) that the common hallway restroom toilet was unclogged the same day. On 06/22/22, LPA observed common hallway restroom toilet was not clogged, flushing properly and in good repair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that facility restroom is in disrepair is unsubstantiated.

Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7