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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 05:16:42 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
07/06/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210706122616
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:
04:30 PM
MET WITH:Alberto Maldonado, Administrator/Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident is being illegally evicted
Facility is incorrectly billing an SSI resident
INVESTIGATION FINDINGS:
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On 01/05/22 at 4:30PM, 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 is being illegally evicted
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, LPA confirmed with administrator that resident (R1) was given a 30 day notice of eviction by the facility dated 05/03/2021 due to non-payment of the rate of basic services from 11/01/2020 to 04/30/2021. Effective date of termination was 06/02/2021. The facility has been informed of the resident's SSI status but they have proceeded with the eviction process. 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 3
Control Number 15-AS-20210706122616
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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Allegation: Facility is incorrectly billing an SSI resident
Based on interviews and record reviews, LPA confirmed with neutral witness (W1) that R1 continues to be billed at the market rate even though facility have been informed of the resident's SSI eligibility and have been requested to send a bill for the correct amount. The preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiencies are 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 3
Control Number 15-AS-20210706122616
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
87368.1(b)(1)
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(b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection (1) Deny admission to a facility, transfer or refuse to transfer a resident within the facility or to another facility, or discharge or evict a resident from a facility...
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Administrator corrected deficiency on 07/28/2021 where R1's notice of eviction was revoked.
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This requirement was not met as evidenced by improper eviction of resident (R1) which posed a potential health & safety risk to resident in care
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Type B
01/05/2022
Section Cited
CCR
87464(e)
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If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident.
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Administrator corrected deficiency on 07/28/2021. R1's monthly invoices from 11/2020 until 07/2021 were adjusted to reflect the appropriate SSI rate.
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This requirement was not met as evidenced by resident being charged the market rate 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: 3 of 3