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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:09:09 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
01/30/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240130115751
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: 96DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Siobhan Lehman,Executive Director TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff spoke to residents in an inappropriate manner.
INVESTIGATION FINDINGS:
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On 5/14/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director, Siobhan Lehman.

On the allegation facility Staff spoke to residents in an inappropriate manner. Based on record review and interviews the facility staff was removed from cleaning R1’s room at R1’s request. After S3 was removed S3 confronted R1 about the situation.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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
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
01/30/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240130115751

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: DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Siobhan Lehman,Executive Director TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not take appropriate steps to prevent the spread of communicable diseases.
Licensee does not ensure facility is in good repair. (push button at front door)
Staff did not provide adequate food service to resident. (delivery)
Staff did not respond to resident requests for assistance in a timely manner.
Licensee does not ensure facility is free from odors.
Staff did not provide adequate food service to resident.
Staff did not provide adequate evacuation assistance for residents.
INVESTIGATION FINDINGS:
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On 5/14/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director, Siobhan Lehman.

On the allegation facility Staff did not take appropriate steps to prevent the spread of communicable diseases. Based on record review and interviews the facility reported to licensing’s and public health as soon as they were made aware of the situation. The facility then followed all orders given by public health including closing the dining room until they were cleared.

On the allegation facility Licensee does not ensure facility is free from odors. Based on observation and interviews the facility hallways and elevator does not have an odor. S1 stated that if there is ever an incontinence accident facility staff clean and sanitize the area immediately.
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240130115751
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 CONCORD
FACILITY NUMBER: 079200855
VISIT DATE: 05/14/2024
NARRATIVE
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...Continued from 9099A

On the allegation facility Staff did not provide adequate food service to resident. Based on record review and interviews the facility serves meals at regular times each day in the dining room. Residents cans opt in to having there meals delivered to there rooms or if the facility is having a public health situation they will provide meal service to all residents. If the resident opts in the dining or care staff will be notified who needs delivery. if a resident is missed, one the staff are notified they will make a meal for the missed resident.

On the allegation facility staff does not ensure facility is kept in good repair at all times. Based on record review and interviews the facility did have a plumbing problem with one of the hallway bathrooms. S1 has been working with the maintenance staff trying to fix this issue. S1 explained that the issue was much deeper in the plumbing and required city work to fix. The work was scheduled and completed.

On the allegation facility staff did not provide adequate evacuation assistance for residents. Based on record review and interviews the facility does have an evacuation chair in the stairwell. The facility has regular fire drills that they record.

On the allegation facility staff did not respond to resident requests for assistance in a timely manner. Based on record review and interviews the facility does have a call button system that records the calls from the residents, the system is not able to print the logs but LPA observed a low response time in the system.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

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: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240130115751
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 CONCORD
FACILITY NUMBER: 079200855
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2024
Section Cited
CCR
87468.1(a)(1)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The facility agrees to go over resident personal rights in the next staff meeting. A sign in sheet will be sent to CCLD by POC date
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Based on LPAs interview licensee did not comply with the section above by the facility staff yelling at
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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: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4