079200748-7-23-2024-15-AS-BFOG-D7GUHJ-20240724153601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:02:03 PM

Unsubstantiated

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
05/10/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240510155002

FACILITY NAME:	TREVISTA ANTIOCH		FACILITY NUMBER:	079200748
ADMINISTRATOR:	ALBERTO MALDONADO		FACILITY TYPE:	740
ADDRESS:	3950 LONE TREE WAY		TELEPHONE:	(925) 470-3395
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	131	CENSUS: 113	DATE:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Alberto Maldonado, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility retained resident with restricted health condition

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 07/23/24 at 12:45PM, Licensing Program Analyst (LPAs) D Panlilio conducted an unannounced subsequent visit and delivered the investigation findings to the administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Facility retained resident with restricted health conditions
Investigation Finding: Unsubstantiated
Based on the department’s observations and interviews which were conducted and record review(s), resident (R1) was first admitted at the facility on 10/31/22. R1 initially developed a stage 2 coccyx wound on 08/23/23. Staff communicated with her primary care physician (PCP) who ordered a wound care treatment plan with home health (HH) visits three times per week from 08/23/23 to 04/26/24.
Continued on next page, LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20240510155002

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: 07/23/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Review of HH notes stated that R1 had a very slow healing wound due to her being diabetic which progressed from a stage 2 to a stage 3 shallow wound pressure injury. Staff assisted R1 in keeping the wound dry and pressure off the wound area. Staff continued to communicate with R1’s PCP on R1’s wound’s status and followed doctor’s orders for new medications. On 05/08/24, R1 was transferred to a skilled nursing facility (SNF) for continued wound care and still remains at the SNF currently.

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 retained resident with restricted health condition is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 2