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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:26:27 PM



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
10/20/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201020142344
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: 109DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alberto Maldonado, AdministratorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident was attacked by another resident while in care
INVESTIGATION FINDINGS:
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On 01/05/22 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent complaint visit, met with administrator, explained the purpose of the visit and delivered investigation findings.

Allegation: Resident was attacked by another resident while in care
Investigation finding: SUBSTANTIATED
Based on LPA’s interviews which were conducted and record review(s), on 04/08/2020 at 6:35PM, facility staff fournd resident (R1) sitting on the floor with resident (R2) sitting on the couch. R1 stated R2 hit him on the face. Staff assessed R1 and observed R1 had a bump on the head and scratch on the nose. 911 was called and R1 was transported to the hospital. The preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Continued on next page, LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20201020142344
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: 01/05/2022
NARRATIVE
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Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/20/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20201020142344

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: 109DATE:
01/05/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alberto Maldonado, AdministratorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident sustained multiple injuries while in care
INVESTIGATION FINDINGS:
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On 01/05/22 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent complaint visit, met with administrator, explained the purpose of the visit and delivered investigation findings.
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Allegation: Resident sustained multiple injuries while in care
Investigation finding: UNSUBSTANTIATED
Based on LPA’s interviews which were conducted and record review(s), resident (R1) had two unwitnessed falls at the facility (10/16/2020 & 10/19/2020) reported by staff. On the first incident dated 10/16/2020, R1 had an unwitnessed fall. Staff observed R1 has a medium sized lump on the back of his head. R1 told staff that he lost his balance moving things around in his apartment.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20201020142344
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: 01/05/2022
NARRATIVE
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R1 was sent to the hospital the same day (10/16/2020) and was cleared by the hospital to return to the facility with no new medications, Xray, CT scan all clear.

On the second incident dated 10/19/2020, R1 had another un-witnessed fall at his apartment. Staff observed R1 had a significant bruise on his left leg and what looked like a broken nose. Staff immediately called 911 and sent R1 to the hospital for evaluation. Administrator stated that R1 never returned back to the facility from the hospital. R1 decided to relocate to another facility. 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 is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20201020142344
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2022
Section Cited
CCR
87468.1(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by R1 being attacked
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Administrator corrected deficiency on 04/08/2020. Both residents were immediately redirected by staff and monitored to ensure their safety.
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by another resident which posed a potential health & safety risk to resident in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5