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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 12:45:10 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
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):
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Facility is unsanitary
INVESTIGATION FINDINGS:
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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. Staff stated that the memory care side of the facility was not being cleaned regularly due to lack of house keeping staff. Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of 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: 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)
Page: 1 of 2
Control Number 15-AS-20220929093215
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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times...This requirement in not met as evidenced by:
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Administrator agreed to review regulation 87303 and submit a self-certification that the regulation has been reviewed. Self-certification shall be submitted to CCLD by POC date. Facility will also submit to CCLD by POC date house keeping staff schedules and evaluate the cleaning needs of the facility as a whole.
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Based on LPAs interview licensee did not comply with the section above in facility not being kept clean in the memory care uint, which poses a potential health and safety risk to persons in care.
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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: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
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