079200855-9-12-2023-15-AS-KHOS-CW9L54-20231003082633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:34:04 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
05/23/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230523152123

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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Facility failed to safeguard resident valuables
Facility in disrepair
Facility failed to safeguard resident medications
Facility failed to provide proper notice for rent increase

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.

During the initial 10-day complaint investigation visit LPA obtained records, Physician’s Report, Pre-placement Appraisal, Appraisal/Needs and Services Plan, Admissions agreement, Personal properties and Valuables list, Visitors Log, Rate increase notice, R1’s POA, and facility maintenance report.

Based on R1’s Physicians report dated 10/13/2022, R1 needs medical supervision relating to medication administration. When the facility was made aware of this, they followed the Physicians report and started assisting with the medication management.

Continued on LIC 9099C...

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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Control Number 15-AS-20230523152123

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: 09/12/2023

NARRATIVE

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Continued from 9099

Based on interviews and records review R1 did not fill out the Personal Properties and Valuables list and could not confirm when the items went missing or exactly what items were in the lock box.

Based on records review the licensee did follow the regulations of rate increase by providing a letter to the resident on 05/26/2023 stating the amount and the reason for the rate increase and dating the effective date for August 1, 2023.

Based on interviews and record reviews The facility did contact and contract out for repairs that were done on R1’s roof. The invoice states that Ramones home improvement did four repairs on 02/09/2023 at the facility including item #1 seal 100 linear feet of metal cooping on the roof line.

Although the allegations may have occurred or are valid, there is 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.

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

LIC9099 (FAS) - (06/04)

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