079200748-9-26-2024-15-AS-KHOS-D9MJZN-20241001072948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:25:28 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
07/18/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240718155310

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:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Alberto Maldonado, Executive Director/Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not honor restraining order for resident

INVESTIGATION FINDINGS:

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On 09/26/24 at 2:50PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver the finding of above allegation. LPA explained the purpose of the visit with ED.

On 07/23/24, LPA obtained the following documents from ED on resident (R1): Restraining Order for other resident (R2) effective December 29, 2023, Power of Attorney to witness (W1) effective February 24, 2024, R1’s Physician's report dated 09/09/23, Needs & Services Plan, R1 Emails, R1’s physicians’ statements, Elder Abuse Concerns & mandated reporting – R1 sent by family lawyer (FL) dated January 4, 2024, R2 sign out records from 12/29/23 until 02/15/24.
Continued on next page, LIC 9099-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: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240718155310

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: 09/26/2024

NARRATIVE

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Allegation: Staff did not honor restraining order for resident
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed resident’s admission agreement dated 09/09/23 which showed he was first admitted at the facility on the same date. Review of R1’s physician’s report dated 07/18/23 showed R1 was diagnosed with dementia and should be escorted by staff due to cognitive impairment. However, review of R1’s latest physician’s report dated 01/31/24 showed R1 was ambulatory, in good physical condition and was able to leave the facility unassisted. On 12/19/23, Executive Director (ED) notified R1’s authorized representative (POA) that R1 left the facility in the company of another resident (R2) using her personal vehicle after ED advised R2 not to do so. A missing person's report was filed with the local police department. ED stated R1 and R2 returned to the facility on the same day, 12/19/23. Due to R2’s constant involvement with R1’s communications and finances, an Elder Abuse Temporary Restraining Order (TRO) was filed by R1’s POA and was granted by the Contra Costa County Superior Court. The TRO required R2 To stay at least 2 yards (6 feet) away from R1 and not to interfere with his finances or communications in any way. Family lawyer (FL) served R2 with the TRO effective 12/29/23 and emailed a copy to facility staff on 01/03/24. ED stated he met with R2 on 12/29/23, discussed the TRO and R2 agreed to honor the TRO. ED stated R2 was observed constantly out of the facility by staff to avoid seeing R1. Review of R2’s sign out records from 12/29/23 until 02/15/24 showed R2 left the facility frequently to spend more time with family and friends. On 02/18/24, R1 had a stroke and was sent to the hospital for treatment. On 02/24/24, R1 appointed his brother (W1) and granted W1 power of attorney for his medical and financial decisions. The hospital transferred R1 to a skilled nursing facility where his health continued to decline. R1 was later transferred to another skilled nursing facility and passed away on 06/22/24. 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 did not honor restraining order for resident is unsubstantiated.

No deficiencies cited during visit.

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: 09/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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