079200748-9-13-2022-15-AS-KHOS-CJVGWY-20221004054306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 09/13/2022
Date Signed: 09/13/2022 01:42:38 PM

Unsubstantiated

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
09/12/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220912114903

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:	DATE:	09/13/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:			TIME COMPLETED:	01:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not able to adequately communicate with residents
Staff are not cleaning up after residents are done eating

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/13/22 at 12:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with executive director (ED), gathered information and delivered investigation findings to ED. LPA explained the purpose of the visit with ED.

During visit, LPA toured the memory care unit with ED and introduced LPA to 3 staff (S1, S2, S3) working the AM shift. ED stated that all staff are required to speak and write in english prior to employment. ED stated that most staff are bilingual (Spanish & English) and are required to communicate in english to residents and other staff. LPA spoke to S1, S2 and S3 in english and they responded back to LPA in english. LPA observed 3 staff asking residents if they wanted more juice or water in english during their lunch meals. Residents responded back to staff with requests for additional water, juice or other entrees. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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 2

Control Number 15-AS-20220912114903

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: 09/13/2022

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 meals were served in plates and trays to residents on each dining table with drinks. LPA did not observe any coffee cups on the floor in the dining or bedroom areas.
LPA observed some meals were delivered and served inside residents' bedrooms on tray tables. LPA observed S3 assisting a resident inside her bedroom with her lunch meal during visit. LPA also observed staff clearing used meal trays, plates and cups from the dining tables as soon as residents are done with their meals.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited during visit. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2