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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 06/06/2025
Date Signed: 06/06/2025 01:57:50 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
03/17/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250317123152
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: 118DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:David Clawson, Administrator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff not maintaining resident’s hygiene
INVESTIGATION FINDINGS:
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On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson.

On the allegation: Staff not maintaining resident’s hygiene
Based on observation and intoerviews, R1 was found to be covered in dried feces. S3 stated that they were shocked when it was pointed out and that they cleaned up R1 as soon as they knew. S3 said that they had newer staff at that time and they were still learing the care rutines.

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:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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
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
03/17/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250317123152

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: 118DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:David Clawson, Administrator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not provide resident with clean linens
Staff are not properly trained to provide care for residents
INVESTIGATION FINDINGS:
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On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson.

On the allegation: Staff did not provide resident with clean linens
Based on record review and interviews, when R1 was found covered in feces, the staff check R1's room and found that the bed and other areas needed cleaning. The care staff notified housekeeping and R1's room was cleaned and the soild laundry was taken to the laundry room.

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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-20250317123152
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: 06/06/2025
NARRATIVE
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Continued from LIC 9099-A

On the allegation: Staff are not properly trained to provide care for residents, based on record review and interviews, New staff receive on boarding training including but not limited to hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living
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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250317123152
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: 06/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
87468.1(a)(2)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Executive Director has hired additional staff to meet care and hygiene needs of residents
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Based on observation and interviews there was not adequate staffing to meet residents needs.
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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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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