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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200855
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:21:09 PM


Document Has Been Signed on 07/07/2023 02:21 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: 96DATE:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Siobhan Lehman, Executive DirectorTIME COMPLETED:
02:30 PM
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On 07/07/2023 at 01:40 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Siobhan Lehman, Executive Director.

LPA was following up on an incident report that was submitted to the department involving staff hitting a resident. LPA obtained additional information and confirmed that the staffs employment was terminated after this incident. No additional follow up needed at this time.


Exit interview conducted. 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: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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