Trevista Antioch

Allegation investigated: Staff do not accord resident privacy

On 01/21/26 3:58PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with Manager on Duty (MOD) and delivered investigation finding. LPA explained the purpose of the visit with MOD. On 01/14/26, LPA obtained the following documents from manager on duty (MOD): Personnel record (LIC500), Residents roster, Fall detection system (Sage Motion Detectors) notification to residents and responsible parties dated 12/12/25. Continued on next page, LIC9099-C Unsubstantiated Allegation: Staff do not accord resident privacy Investigation Finding: Unsubstantiated During investigation LPA interviewed reporting party (RP), staff (Manager on Duty (MOD, Regional Director (RD) and reviewed the Sage Fall Detection System notification letter sent to residents on 12/12/25. RP stated that the facility has installed AI fall cameras in all resident bedrooms including memory care (sign notification on the door walking into memory care) which are capable of fall detection and motion/video recording. On 01/14/26 at 3:30PM, LPA toured the facility and observed the motion detector devices installed inside assisted living and memory care residents’ bedrooms. RD stated that the Sage Motion Detectors are not surveillance cameras. They are motion detectors which do not record any audio or continuous live monitoring. RD stated that the facility will hold informational meetings about the Sage motion detection system for additional education, understanding of the system and consent forms will be provided to all residents, authorized representatives, family members who would like to avail of the fall detention system service. MOD stated residents who decide not ot avail of the Sage fall detection system will have the device covered and inactive from the system. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not accord resident privacy is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 15-AS-20260108151520

Type of visit: Case Management - Incident

On 01/21/26 at 4:40PM, while at the facility for another reason, LPA D Panlilio spoke with Manager on Duty (MOD) and Wellness Director (WD) regarding the sefl reported sexual abuse incident on 01/14/26. LPA obtained the following information from MOD and WD: On 01/15/26, resident (R1) disclosed that on 01/04/26 and 01/08/26, during shower assistance provided by caregiver (S1), R1 stated that S1 allegedly touched her genital area inappropriately. R1 reported the incident to her family member during a phone conversation at a later date, who in turn reported it to management for investigation. The facility notified local police who investigated S1 the same day and also sent SOC341 to Ombudsman. WD stated R1 has mild dementia and did not want to be evaluated. A police report# 26-385 was filed. WD conducted an internal investigation and interviewed 5 other residents (R2, R3, R4, R5,R6) under S1's care. They stated that staff (including S1) are great, kind, helpful, provide good care and that they have no concerns with staff. LPA interviewed S1 who stated that she did not inappropriately touch R1 in her genital area during the 2 weekly showers she gave her. S1 stated R1 was holding onto the bath grab bar with one hand and had pain in her other hand. S1 stated R1 requested her to clean her with a wash cloth. S1 cleaned R1's side groin area with the wash cloth and denied touching her inappropriately. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Required - 1 Year

On 01/14/26 at 4PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required one year inspection and met with staff (Manager on duty (MOD), Wellness Director (WD)). LPA explained the purpose of the visit with MOD and WD. At 04:10PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the front desk screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 70 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 11/10/26. LPA observed stairwell lift chairs for evacuation. Inside and outside pathways were observed clear and free of fire hazards. LPA reviewed 5 staff and 10 resident files. Continued on next page, LIC 809-C Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Resident sustained multiple pressure injuries due to lack of care from staff Staff did not ensure that resident needs were met while in care

On 11/07/25 at 3:10PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, the Department obtained the following documents from administrator – Residents’ admission agreements, physician's reports, Needs/Services plans, appraisals, medication administration records, hospital visit discharge reports, Level of care notes & ADL schedules. Health & safety check conducted see LIC 809 dated 05/16/25. Continued on next page, LIC 9099-C Substantiated Allegation: Resident sustained multiple pressure injuries due to lack of care from staff Investigation Finding: Substantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ED, S1, S2, S3, S4) & R1’s responsible party (POA): and reviewed resident (R1) documents. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. POA also confirmed that R1 moved into the facility on 04/27/25 without any pressure injuries. During interview, the Memory Care Director also stated that R1 was admitted with no pressure injuries. The Department observed that R1’s care plan included the skin treatment routine of keeping the skin clean and dry, apply over the counter skin care cream, and monitor for any redness, irritation, and/or open skin, however, the facility’s Task Administration Record showed no care entries for the Skin Treatment Routine were performed from April 27, 2025 through May 11, 2025. Three caregiver staff reported to the Department that they had changed R1s incontinence wear, clothing, and provided a shower, and denied noticing anything other than chafing or surface level redness. However, R1 was picked up by POA on 05/11/25 to return home after living at the facility for about 15 days and on the same day, the POA discovered a pressure injury and took R1 to the hospital where she was diagnosed with stage 3 infected pressure injuries. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident sustained multiple pressure injuries due to lack of care from staff was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining multiple pressure injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury. Continued on next page, LIC 9099-C pg2 Allegation: Staff did not ensure resident’s needs were met while in care Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff (ED, S1 S2, S3, S4), responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted to at the facility on 04/27/25 for respite care and resided at the facility for 15 days until 05/11/25. R1 was assessed as having cognitive impairment, was ambulatory with a cane/wheelchair, neededs standby assistance transferring in & out of bed, total assistance with ADLs (showering, incontinence care, toileting, grooming, dressing, feeding) and was a high risk for falls. POA agreed to place R1 in the memory care unit so that she R1 can have additional staff care support. Review of R1’s files showed no documentation of any pre-existing pressure injuries upon admission. During staff interviews, some staff stated they had noticed redness near the coccyx during R1’s stay, but since it appeared to be only surface level, they did not report any concerns. Staff denied observing any pressure injuries, although the Task Administration Record (TAR) for R1 showed no entries for “Skin Treatment Routine” were performed from for 04/27/25 through 05/11/25. The Skin Treatment Routine was identified as a service need. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not ensure resident’s needs were me while in care was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Nov 7, 2025 · control 15-AS-20250514175501

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Nov 7, 2025

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed a potential health & safety risk to residents in care. This requirement was not met as evidenced by resident (R1) developing multiple pressure injuries which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in hospitalization and sustaining multiple pressure injuries while in care. Additional civil penalty determination is pending relating to resident’s serious bodily injury. A non-compliance conference meeting with CCLD will be scheduled at a later time.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 5, 2025

Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… This requirement was not met as evidenced by staff failing to provide adequate care & supervision which posed an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2025

Plan of correction: By POC due date, administrator agreed to complete and submit in-service staff retraining certifications by an approved CCL vendor on personal rights of residents in compliance with Section 87468.2 (a)(4).

Type of visit: Case Management - Incident

On 07/01/25 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced case management visit and met with executive director (ED). LPA explained the purpose of the visit with ED. On 06/30/25, the facility self reported an incident that occurred on 06/28/25 at 10AM between two dementia residents (R1, R2) who started yelling and hitting each other in front of the elevator. Staff intervened and redirected them. Staff checked both residents and observed no injuries. On 06/30/25, R2 moved out of the facility as she was already scheduled to move out of the facility in July to be closer to family members. No deficiency cited during visit. Exit interview conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Required - 1 Year

On 02/27/24 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required one year inspection and met with Administrator (ADM). LPA explained the purpose of the visit with ADM. LPA observed facility is still under quarantine for positive cases of COVID-19. ADM stated COVID surveillance will be lifted on 01/17/25. At 2:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the front desk screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 71 deg F. Hot water temperature was measured at 116 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 01/02/25. LPA observed stairwell lift chairs for evacuation. Inside and outside pathways were observed clear and free of fire hazards. LPA reviewed 5 staff and 5 resident files. Continued on next page, LIC 809-C Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Case Management - Incident

On 11/07/2024 at 02:43PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 11/04/2024. LPA met with Alberto Maldonado, Executive Director (ED) and explained the purpose of the visit. The incident occurred on 11/04/2024 at 1:15PM which involved a resident (R1) hitting another resident (R2) with his cane across R2’s forearm. LPA interviewed ED who stated both R1 and R2 were waiting for the elevator to arrive in the lobby area, when R1 struck R2 with his cane across the forearm, stating R2 stole his jewelry from him. After staff accessed the situation, it turned out that R2 didn’t have jewelry but did have a snicker candy bar in his hand. ED stated both R1 and R2 has history from dating the same women on the past. R1 has dementia, ED in the process of reaching out to R1’s Physician regarding possibly adjusting R1’s medication. ED also stated in the process of writing a letter to R1’s responsible party(granddaughter) advising of final warning of violation of house rules/misconduct. Both R1 and R2 has agreed to stay away from each other. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2024

Allegation investigated: Staff did not honor restraining order for resident

On 09/26/24 at 2:50PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with executive director (ED) to deliver the finding of above allegation. LPA explained the purpose of the visit with ED. On 07/23/24, LPA obtained the following documents from ED on resident (R1): Restraining Order for other resident (R2) effective December 29, 2023, Power of Attorney to witness (W1) effective February 24, 2024, R1’s Physician's report dated 09/09/23, Needs & Services Plan, R1 Emails, R1’s physicians’ statements, Elder Abuse Concerns & mandated reporting – R1 sent by family lawyer (FL) dated January 4, 2024, R2 sign out records from 12/29/23 until 02/15/24. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff did not honor restraining order for resident Investigation Finding: Unsubstantiated During investigation, LPA reviewed resident’s admission agreement dated 09/09/23 which showed he was first admitted at the facility on the same date. Review of R1’s physician’s report dated 07/18/23 showed R1 was diagnosed with dementia and should be escorted by staff due to cognitive impairment. However, review of R1’s latest physician’s report dated 01/31/24 showed R1 was ambulatory, in good physical condition and was able to leave the facility unassisted. On 12/19/23, Executive Director (ED) notified R1’s authorized representative (POA) that R1 left the facility in the company of another resident (R2) using her personal vehicle after ED advised R2 not to do so. A missing person's report was filed with the local police department. ED stated R1 and R2 returned to the facility on the same day, 12/19/23. Due to R2’s constant involvement with R1’s communications and finances, an Elder Abuse Temporary Restraining Order (TRO) was filed by R1’s POA and was granted by the Contra Costa County Superior Court. The TRO required R2 To stay at least 2 yards (6 feet) away from R1 and not to interfere with his finances or communications in any way. Family lawyer (FL) served R2 with the TRO effective 12/29/23 and emailed a copy to facility staff on 01/03/24. ED stated he met with R2 on 12/29/23, discussed the TRO and R2 agreed to honor the TRO. ED stated R2 was observed constantly out of the facility by staff to avoid seeing R1. Review of R2’s sign out records from 12/29/23 until 02/15/24 showed R2 left the facility frequently to spend more time with family and friends. On 02/18/24, R1 had a stroke and was sent to the hospital for treatment. On 02/24/24, R1 appointed his brother (W1) and granted W1 power of attorney for his medical and financial decisions. The hospital transferred R1 to a skilled nursing facility where his health continued to decline. R1 was later transferred to another skilled nursing facility and passed away on 06/22/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not honor restraining order for resident is unsubstantiated. No deficiencies cited during visit. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 15-AS-20240718155310

Allegation investigated: Facility retained resident with restricted health condition

On 07/23/24 at 12:45PM, Licensing Program Analyst (LPAs) D Panlilio conducted an unannounced subsequent visit and delivered the investigation findings to the administrator (ADM). LPA explained the purpose of the visit with ADM. Allegation: Facility retained resident with restricted health conditions Investigation Finding: Unsubstantiated Based on the department’s observations and interviews which were conducted and record review(s), resident (R1) was first admitted at the facility on 10/31/22. R1 initially developed a stage 2 coccyx wound on 08/23/23. Staff communicated with her primary care physician (PCP) who ordered a wound care treatment plan with home health (HH) visits three times per week from 08/23/23 to 04/26/24. Continued on next page, LIC9099-C Unsubstantiated Review of HH notes stated that R1 had a very slow healing wound due to her being diabetic which progressed from a stage 2 to a stage 3 shallow wound pressure injury. Staff assisted R1 in keeping the wound dry and pressure off the wound area. Staff continued to communicate with R1’s PCP on R1’s wound’s status and followed doctor’s orders for new medications. On 05/08/24, R1 was transferred to a skilled nursing facility (SNF) for continued wound care and still remains at the SNF currently. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation that facility retained resident with restricted health condition is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 15-AS-20240510155002

Type of visit: Case Management - Incident

On 07/23/24 at 1:40PM, LPA D Panlilio conducted an unannounced case management as a result of receiving an incident report (SOC341) on 07/03/24 regarding aggressive behaviors between resident (R1) and staff (S1). ADM stated that S1 reported that on 07/02/24, she was providing care to R1 who became aggressive towards her and attempted to scratch her face. S1 held R1’s right wrist in self -defense. The following day it was noted that R1’s right wrist had some bruising and swelling. R1 denied pain or discomfort. Antioch police report was filed (Ref# 24-038542). ADM stated S1 was suspended on 07/04/24 and completed in-service staff retraining on proper redirection/handling of residents with aggressive behaviors. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Required - 1 Year

On 02/27/24 at 12PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required one year inspection and met with Administrator (ADM). LPA explained the purpose of the visit with ADM. At 01:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the front desk screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 01/07/24. LPA observed stairwell lift chairs for evacuation. Inside and outside pathways were observed clear and free of fire hazards. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Continued on next page, LIC 809-C Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 27, 2024

Type of visit: Case Management - Incident

On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a SOC 341 self reported incident that occurred on 11/25/23. LPA spoke with Alberto Maldonado, Executive Director and explained the purpose of the visit. LPA received an SOC 341 self reported regrading a resident hitting another resident while in the community. LPA interviewed S1 regrading the incident. S1 stated that the situation has been resolved. S1 spoke with the victim family members and explained the situation. R1 was place on Hospice after the incident. Prior to the incident R1 tend to have a behavior of going door to door of other residents and enter their room. R2 didn’t like what R1 was doing R2 chanting at R1 (don’t you dare go inside my room). R1 got irritated while walking pass R2, R1 brush R2 away. R2 was brushed away by R1 there were no injury to R2, and R2 was check for any other injury cause by the brushing. R1 is now on hospice and now med compliance. LPA reviewed and obtained: - Resident roster and staff roster - R1 admission to hospice new order for medication. - R1 assessment. - R1 progress notes - Day of incident police report number: E23066740 No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 14, 2023