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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200748
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:23:07 PM

Document Has Been Signed on 11/07/2024 03:23 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TREVISTA ANTIOCHFACILITY NUMBER:
079200748
ADMINISTRATOR/
DIRECTOR:		ALBERTO MALDONADOFACILITY TYPE:
740
ADDRESS:3950 LONE TREE WAYTELEPHONE:
(925) 470-3395
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 131TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:43 PM
MET WITH:Alberto Maldonado,, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:53 PM
NARRATIVE
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On 11/07/2024 at 02:43PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 11/04/2024. LPA met with Alberto Maldonado, Executive Director (ED) and explained the purpose of the visit.

The incident occurred on 11/04/2024 at 1:15PM which involved a resident (R1) hitting another resident (R2) with his cane across R2’s forearm. LPA interviewed ED who stated both R1 and R2 were waiting for the elevator to arrive in the lobby area, when R1 struck R2 with his cane across the forearm, stating R2 stole his jewelry from him. After staff accessed the situation, it turned out that R2 didn’t have jewelry but did have a snicker candy bar in his hand.

ED stated both R1 and R2 has history from dating the same women on the past. R1 has dementia, ED in the process of reaching out to R1’s Physician regarding possibly adjusting R1’s medication. ED also stated in the process of writing a letter to R1’s responsible party(granddaughter) advising of final warning of violation of house rules/misconduct.

Both R1 and R2 has agreed to stay away from each other.


No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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