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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200748
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:10:07 PM


Document Has Been Signed on 07/23/2024 02:10 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: 118DATE:
07/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Alberto Maldonado, AdministratorTIME COMPLETED:
02:30 PM
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On 07/23/24 at 1:40PM, LPA D Panlilio conducted an unannounced case management as a result of receiving an incident report (SOC341) on 07/03/24 regarding aggressive behaviors between resident (R1) and staff (S1).

ADM stated that S1 reported that on 07/02/24, she was providing care to R1 who became aggressive towards her and attempted to scratch her face. S1 held R1’s right wrist in self -defense. The following day it was noted that R1’s right wrist had some bruising and swelling. R1 denied pain or discomfort. Antioch police report was filed (Ref# 24-038542).

ADM stated S1 was suspended on 07/04/24 and completed in-service staff retraining on proper redirection/handling of residents with aggressive behaviors.

No deficiencies cited. 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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