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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200855
Report Date: 12/04/2023
Date Signed: 12/04/2023 03:46:34 PM


Document Has Been Signed on 12/04/2023 03:46 PM - It Cannot Be Edited

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: 92DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Siobhan Lehman, Executive DirectorTIME COMPLETED:
04:00 PM
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On 12/04/2023 at 09:20 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA met with Executive Director Siobhan Lehman and explained the purpose of the visit. The facility is licensed for 160 non ambulatory residents. The facility has a hospice waiver for Ten (10) residents.

LPA inspected the facility inside out. The facility consists of 112 total bedrooms. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. A comfortable temperature is maintained at 74 Degrees Fahrenheit. LPA inspected the living room, theater room, café, dining area, kitchen, bedrooms, hallways, bathrooms, courtyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with walk-in refrigerator and freezer, industrial dishwasher, washers, and dryers. Medications were stored in the medication that was observed locked. Activity supplies were available along with an actives calendar. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 02/20/2023.



At 10:25 am LPA reviewed 10 residents’ records. At 12:45 pm, LPA reviewed 5 staff records and 5 of 5 were fingerprint cleared and associated to the facility.

No deficiencies cited during visit. Exit interview conducted 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: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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