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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200748
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:26:36 PM


Document Has Been Signed on 12/14/2023 04:26 PM - It Cannot Be Edited

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:ALBERTO MALDONADOFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(925) 470-3395
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:131CENSUS: 112DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alberto Maldonado, Executive DirectorTIME COMPLETED:
04:45 PM
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On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a SOC 341 self reported incident that occurred on 11/25/23. LPA spoke with Alberto Maldonado, Executive Director and explained the purpose of the visit.

LPA received an SOC 341 self reported regrading a resident hitting another resident while in the community. LPA interviewed S1 regrading the incident. S1 stated that the situation has been resolved. S1 spoke with the victim family members and explained the situation. R1 was place on Hospice after the incident. Prior to the incident R1 tend to have a behavior of going door to door of other residents and enter their room. R2 didn’t like what R1 was doing R2 chanting at R1 (don’t you dare go inside my room). R1 got irritated while walking pass R2, R1 brush R2 away. R2 was brushed away by R1 there were no injury to R2, and R2 was check for any other injury cause by the brushing. R1 is now on hospice and now med compliance.

LPA reviewed and obtained:

- Resident roster and staff roster
- R1 admission to hospice new order for medication.
- R1 assessment.
- R1 progress notes
- Day of incident police report number: E23066740


No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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