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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200748
Report Date: 11/07/2025
Date Signed: 11/07/2025 03:51:29 PM

Substantiated


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
05/14/2025 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20250514175501
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: 116DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Erika Mendez, Manager on DutyTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries due to lack of care from staff
Staff did not ensure that resident needs were met while in care
INVESTIGATION FINDINGS:
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On 11/07/25 at 3:10PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the Department obtained the following documents from administrator – Residents’ admission agreements, physician's reports, Needs/Services plans, appraisals, medication administration records, hospital visit discharge reports, Level of care notes & ADL schedules. Health & safety check conducted see LIC 809 dated 05/16/25.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
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-20250514175501
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: 11/07/2025
NARRATIVE
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Allegation: Resident sustained multiple pressure injuries due to lack of care from staff
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3, S4) & R1’s responsible party (POA): and reviewed resident (R1) documents. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. POA also confirmed that R1 moved into the facility on 04/27/25 without any pressure injuries. During interview, the Memory Care Director also stated that R1 was admitted with no pressure injuries. The Department observed that R1’s care plan included the skin treatment routine of keeping the skin clean and dry, apply over the counter skin care cream, and monitor for any redness, irritation, and/or open skin, however, the facility’s Task Administration Record showed no care entries for the Skin Treatment Routine were performed from April 27, 2025 through May 11, 2025. Three caregiver staff reported to the Department that they had changed R1s incontinence wear, clothing, and provided a shower, and denied noticing anything other than chafing or surface level redness. However, R1 was picked up by POA on 05/11/25 to return home after living at the facility for about 15 days and on the same day, the POA discovered a pressure injury and took R1 to the hospital where she was diagnosed with stage 3 infected pressure injuries.

Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident sustained multiple pressure injuries due to lack of care from staff was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining multiple pressure injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury.

Continued on next page, LIC 9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20250514175501
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: 11/07/2025
NARRATIVE
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Allegation: Staff did not ensure resident’s needs were met while in care
Investigation Finding: Substantiated
During investigation, the Department conducted interviews of facility staff (ED, S1 S2, S3, S4), responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted to at the facility on 04/27/25 for respite care and resided at the facility for 15 days until 05/11/25. R1 was assessed as having cognitive impairment, was ambulatory with a cane/wheelchair, neededs standby assistance transferring in & out of bed, total assistance with ADLs (showering, incontinence care, toileting, grooming, dressing, feeding) and was a high risk for falls. POA agreed to place R1 in the memory care unit so that she R1 can have additional staff care support. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. During staff interviews, some staff stated they had noticed redness near the coccyx during R1’s stay, but since it appeared to be only surface level, they did not report any concerns. Staff denied observing any pressure injuries, although the Task Administration Record (TAR) for R1 showed no entries for “Skin Treatment Routine” were performed from for 04/27/25 through 05/11/25. The Skin Treatment Routine was identified as a service need. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure resident’s needs were me while in care was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250514175501
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: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
HSC
1569.269
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Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed a potential health & safety risk to residents in care.

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Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining multiple pressure injuries while in care.

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This requirement was not met as evidenced by resident (R1) developing multiple pressure injuries which posed an immediate health and safety risk to resident in care.
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Additional civil penalty determination is pending relating to resident’s serious bodily injury.

A non-compliance conference meeting with CCLD will be scheduled at a later time.
Type B
12/05/2025
Section Cited
CCR
87468.2(a)(4)
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Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs…
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By POC due date, administrator agreed to complete and submit in-service staff retraining certifications by an approved CCL vendor on personal rights of residents in compliance with Section 87468.2 (a)(4).

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This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed an immediate health & safety risk to residents 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4