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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200855
Report Date: 11/08/2021
Date Signed: 11/08/2021 11:07:38 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TREVISTA CONCORDFACILITY NUMBER:
079200855
ADMINISTRATOR:THAMES, LORIFACILITY TYPE:
740
ADDRESS:1081 MOHR LNTELEPHONE:
(925) 798-3900
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:160CENSUS: 76DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lori Thames, Director TIME COMPLETED:
11:15 AM
NARRATIVE
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On 11/08/2021 at 8:44am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Director Lori Thames and explained the purpose of the visit.
LPA inspected the facility including but not limited to resident apartments, bathrooms, dining rooms, common living areas, kitchen, and outside areas. The room temperature and lighting were adequate for the safety and comfort of the residents. Rooms were furnished appropriately and observed to be clean and in good repair. All rooms have private bathrooms and showers which were equipped with grab bars and safety/nonskid floors/mats. Food supply was checked and there is an adequate supply of 2 day perishables and 7 day non-perishables. Refrigerator temperature is measured at 29 degrees Fahrenheit. Freezer temperature was measured at 8 degrees Fahrenheit. Kitchen and food preparation areas were observed to be clean and in compliance. There were no bodies of water or fire safety hazards observed.

Facility is equipped with interconnected smoke detectors, sprinklers, and fire alarm. Memory Care unit's door and all other exit doors were with delayed egress. Facility has a mitigation plan, emergency disaster plan, and maintains records of routine screening for residents, staff and visitors, resident's changing of health conditions, and N95 respirators fit testing for staff.

Deficiencies seen as follows;


Hot water temperature were measured on different sides of the building measuring at 128.2 degrees Fahrenheit and 96.3 degrees Fahrenheit.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 CONCORD
FACILITY NUMBER: 079200855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2021
Section Cited

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Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105
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 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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