079200855-3-18-2022-15-AS-KHOS-CCRQ4T-20220322115051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 03/18/2022
Date Signed: 03/18/2022 04:28:24 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
03/27/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200327115015

FACILITY NAME:	TREVISTA CONCORD		FACILITY NUMBER:	079200855
ADMINISTRATOR:	THAMES, LORI		FACILITY TYPE:	740
ADDRESS:	1081 MOHR LN		TELEPHONE:	(925) 798-3900
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	160	CENSUS: 71	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	03:14 PM
MET WITH:	Siobhan Lehman, Executive Director		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident was unlawfully evicted

INVESTIGATION FINDINGS:

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On 03/18/22 at 3:14PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced subsequent complaint visit, met with executive director (ED) and delivered investigation finding of above allegation. LPA explained the purpose of the visit with ED.

Based on record reviews and interviews, resident (R1) was issued an eviction notice on 02/12/20 by former ED and resident moved out on 03/30/20. Review of SOC 341 dated 02/12/20 show a note from former ED advising CCLD of R1's 30 day notice of eviction.
Prior to R1 moving out, she was sent to the local hospital on 03/19/20 for diarrhea and vomitting. After treatment, she was released back to the facility. ED stated R1 moved out of the facility on 03/30/20.

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. Exit Interview conducted and a copy of this report provided via email.

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: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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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