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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 10/20/2022
Date Signed: 10/20/2022 12:44:02 PM

Unsubstantiated


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
09/29/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20220929093215
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: 60DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Stephanie Perez, Wellness CoordinatorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
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9
Residents' toilets are inoperative
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
On 10/20/2022 at approximately 10:32 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit meeting with Stephanie Perez, Wellness Coordinator. The purpose of the visit was to deliver findings on the above allegation.

During the course of investigation, LPA obtained information, collected documents and interviewed staff. They stated that the facility is timely on any repairs that are reported to the maintenance staff. The maintenance staff may have a delay in repairs if they have to order the parts needed to fix the issue. 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.
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: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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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