079200748-8-11-2023-15-AS-KHOS-CUWMNK-20230821094540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:55:49 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
04/04/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220404100947

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: 115	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Alberto Maldonado, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff left resident in soiled sheets for extended period of time
Staff are not meeting resident's care needs
Facility is short staffed

INVESTIGATION FINDINGS:

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On 08/11/23 at 11:23 AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver the findings of above allegations. LPA explained the purpose of the visit with ED.

Allegation: Staff left resident in soiled sheets for an extended period of time
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed resident’s (R1) records and observed R1 has resided at the facility since 08/22/2018. She was admitted into hospice care on 03/17/2022 and relocated to the memory care unit due to declining health and dementia. ED stated staff changed memory care residents’ sheets daily or as needed. Review of R1's charting notes confirm R1's sheets were changed daily.
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: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220404100947

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: 08/11/2023

NARRATIVE

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Allegation: Staff left resident in soiled sheets for an extended period of time
Investigation Finding: Unsubstantiated
Continuation...
Review of R1’s care plan show staff provided R1 full assistance with R1’s bathing/showering (2X per week) and daily assistance with dressing/undressing, toileting and wandering. Review of R1’s care plan also showed daily routine checks done by staff every 2 hours as instructed by hospice care team. Based on interviews and record reviews which were conducted, 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 that staff left resident in soiled sheets for an extended period of time is unsubstantiated.

Allegation: Staff are not meeting resident’ s care needs
Investigation Finding: Unsubstantiated
During investigation, LPA reviewed R1’s care plan dated 04/20/2022 which showed nail care was provided by a certified podiatrist every month on the 31^st day or as needed since R1 was a high risk for complications following nail care. ED stated R1 left the facility 05/24/22 and moved to another facility. ED stated R1’s authorized representative met with him in May 2022 because they wanted to move R1 back to the facility due to better care than the facility they moved R1 into. Based on interviews and record reviews which were conducted, 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 that staff are not meeting resident’s care needs is unsubstantiated.

Allegation: Facility is short staffed

Investigation Finding: Unsubstantiated
During investigation LPA observed the memory care unit has 24 dementia residents assisted by 4 staff (2 caregivers, 1 activities assistant and 1 resident care director) on each shift. Residents in care were observed well groomed, odor free and comfortable in their surroundings. Review of R1’s care plan dated 04/20/22 show staff provided R1 full assistance with activities of daily living - bathing (2X per week); toileting, dressing/undressing, grooming, incontinence care, wandering daily with routine checks done every 2 hours as well as implemented hospice care teams’ instructions while in care. 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 that facility is short staffed is unsubstantiated.

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: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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