079200855-9-12-2023-15-AS-KHOS-CW9KRA-20231003080736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:33:02 AM

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
04/06/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230406080437

FACILITY NAME:	TREVISTA CONCORD		FACILITY NUMBER:	079200855
ADMINISTRATOR:	THAMES, LORI		FACILITY TYPE:	740
ADDRESS:	1081 MOHR LN		TELEPHONE:	(925) 798-3900
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	160	CENSUS: 95	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:21 AM
MET WITH:	Siobhan Lehman, Executive Director		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Resident in care was charged for services that he is not receiving

INVESTIGATION FINDINGS:

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On 09/12/2023 at 09:21AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct an unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Siobhan Lehman, Executive Director.

Based on interviews and record reviews, R1 was receiving the level of care that he was paying for. In interviews with both R1 and S1 it was clear that there was a miss communication between them about what services were provided in each level of care. R1’s ledger shows that he did receive a level of care change on 06/02/2023 and the facility did give a concession of $4500 on 07/19/2023.

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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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