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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200855
Report Date: 06/06/2025
Date Signed: 06/06/2025 02:04:57 PM

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
06/03/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250603101418
FACILITY NAME:TREVISTA CONCORDFACILITY NUMBER:
079200855
ADMINISTRATOR:CLAWSON, DAVID JFACILITY TYPE:
740
ADDRESS:1081 MOHR LNTELEPHONE:
(925) 798-3900
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:160CENSUS: 118DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:David Clawson, Administrator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff mistreated a resident while in care
Staff mishandled a resident's medications while in care
INVESTIGATION FINDINGS:
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On 06/6/2025 at 09:05AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator David Clawson.
During the initial 10-day complaint visit. LPA interviewed staff, collected the following documents: R1’s Physicians report, R1’s SNF record, R1’s SNF order summary, Observation notes for R1, R1’s Self-Administration of Medication Assessment, Faxes from R1’s PCP, and medication logs for six residents.

On the allegation: Staff mistreated a resident while in care
Based on record review and interviews, R1 has a history of yelling and cursing at the staff members who were not handling their medications in the way they wanted. In R1’s observation notes indicate 10 different incidents that R1 was rude to or yelled at med tech staff between 5/6/25 and 6/3/25 when the resident un-enrolled from the facilities medication management program.
Continued on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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-20250603101418
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: 06/06/2025
NARRATIVE
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... Continued from LIC-9099

On the allegation: Staff mishandled a resident's medications while in care

Based on record review and interviews, the facility never lost any of R1’s medications and never missed a dose. R1 had medications that they were taking at the Skilled Nursing Facility that were discontinued prior to moving in. R1 had a procedure on 5/13/25 and was prescribed additional medications at this time. R1 started to sign up with Primer which is a subscription for medications which conflicted with R1’s insurance that caused a delay in getting the prescribed medication. R1 changed pharmacies on 5/20/25 and on 5/21/25 picked up the medication without informing the facility. On 6/2/25 R1 was un-enrolled in the facilities medication management program and is handling their medications on their own.

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.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2