079200748-1-5-2022-15-AS-DPAO-CADUJY-20220105143820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200748
Report Date: 01/05/2022
Date Signed: 01/05/2022 02:39:17 PM

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 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: 109	DATE:	01/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Alberto Maldonado, Administrator/Executive Director		TIME COMPLETED:	03:00 PM

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	On 01/05/22 at 1:55PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. Facility has a completed mitigation plan in place dated 01/23/2021 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom check) is done at entry for all staff, residents and visitors. LPA observed COVID-19 signages posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. Facility has 3 spacious living/visitation areas inside for social distancing among residents. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/05/2022

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

LPA observed PPE cart located outside of 1st floor isolation wing. Facility has conducted staff training on infection prevention, symptoms, transmission and proper donning & doffing of PPE. Trash bins with lid operated with foot pedal were located inside bedrooms, bathrooms and kitchen.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since January 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. PPE supplies were observed stored in the 3rd floor storage room.

Facility room temperature was maintained at 72 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

No deficiencies observed during visit. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2