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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 05:57:35 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
07/15/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210715151325
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:
05:25 PM
MET WITH:Alberto Maldonado, Administrator/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not respond to resident's calling for assistance
INVESTIGATION FINDINGS:
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On 01/05/22 at 5:25PM, 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: Staff did not respond to resident's calling for assistance
Investigation Finding: SUBSTANTIATED
Based on LPA's interviews and record reviews, staff (S1) admitted to wellness coordinator that on 07/12/2021 she took resident (R1) to the toilet and never came back for more that 2 hours because she turned her radio down. 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 4
Control Number 15-AS-20210715151325
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 4
Control Number 15-AS-20210715151325
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
87464(4)
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Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications
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Administrator corrected deficiency on 07/16/21. Incident was internally investigated and staff terminated.

Administrator conducts monthly staff meetings to remind all staff
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This requirement was not met as evidenced by staff not responding to resident's calling for assistance which posed a potential health & safety risk to residents in care
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to follow established care and supervision protocols at all times.
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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 4
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
07/15/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210715151325

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:
05:25 PM
MET WITH:Alberto Maldonado, Administrator/Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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9
Staff is retaliating against resident for making a complaint
INVESTIGATION FINDINGS:
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On 01/05/22 at 5:25PM, 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: Staff is retaliating against resident for making a complaint
Investigation Finding: UNSUBSTANTIATED
Based on LPA's interviews and record reviews, staff denied retaliating against resident (R1) for making a complaint. An internal investigation done by administrator regarding R1 being left unattended on 07/12/2021 in the toilet for more than 2 hours resulted in the termination of the staff involved on 07/16/2021. 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.
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: 4 of 4