Inspection Reports for
TreVista Senior Living at Concord

The inspection found repeat violations including broken and missing window screens in memory care and a dirty sink in the assisted living cafe. Immediate civil penalties totaling $500 were assessed for these deficiencies.

The complaint investigation 15-AS-20251118152637 was substantiated based on record review and interviews revealing multiple deficiencies related to resident R1's care and recordkeeping.

The investigation found that the facility failed to maintain resident R1's financial records from 2022, did not notify the licensing agency of multiple fall incidents involving R1, and did not update R1's Appraisal Needs and Services Plan to address repeated falls. Additionally, R1's records were not provided following a written request from the resident or representative.

Complaint investigation (15-AS-20260227093249) was conducted regarding medication administration records for Resident 1. The deficiency was substantiated as the MAR was inaccurate and posed a potential health and safety violation.

The facility was found to have an inaccurate Medication Administration Record (MAR) for Resident 1, with unclear documentation about medication refusal or unavailability, posing a potential health and safety risk.

The visit was complaint-related, investigating complaint 15-AS-20250829120512. The deficiency regarding admissions agreements was substantiated during the investigation.

The inspection found that the facility's admissions agreements did not specify whether residents agreed to shared or private rooms, which is a violation of California Code of Regulation, Title 22. A deficiency was cited for this issue.

The complaint investigation was substantiated for uncleared staff providing care, unmet hygiene needs due to insufficient staffing, and medication administration issues. The allegation regarding improper infection control practices was unsubstantiated.

The investigation substantiated that some staff were not fingerprint cleared or associated with the facility, there were insufficient staff to meet residents' hygiene needs, and medication refills were not timely, resulting in missed dosages. Another allegation regarding infection control practices was unsubstantiated.

The inspection found several deficiencies including unlocked hazardous materials in the laundry room, failure to conduct quarterly disaster drills, and a freezer temperature above the required level. Immediate corrective actions were taken for unlocked hazardous materials during the inspection.

The complaint investigation revealed that resident R1 was not given prescribed medications from 9/01/25 to 9/08/25 and 9/01/25 to 9/18/25 due to unavailable medications. Resident R2 was administered pain medication without a corresponding order for another medication as per Pain Management Clinic instructions. The violation was substantiated and cited as a repeat violation.

The investigation found that one resident was not given prescribed medications due to lack of medication refills, and another resident lacked a proper medication order despite staff instructions. A deficiency was cited with a $250 civil penalty for repeat violation.

The complaint was substantiated. Allegations included unsanitary conditions in a resident's room due to rodent droppings, presence of vermin in the facility, and improper eviction of residents. Evidence showed rodent droppings in resident room 124, the facility's awareness and pest control efforts, and refusal to readmit a resident with dementia who eloped and was hospitalized.

The investigation substantiated that rodent droppings were found in a resident's room, the facility was aware and taking pest control measures, and that the facility improperly refused to readmit a resident who eloped and was hospitalized despite the resident's dementia and inability to leave unattended.

The visit followed a complaint investigation conducted on 2025-08-15 which cited the facility on 4 deficiencies. The POC due dates were 2025-08-26 and 2025-08-29. Deficiencies were not cleared by the follow-up visit.

Four deficiencies cited during the complaint visit were not cleared by this POC visit, resulting in a civil penalty assessment. The facility remains subject to ongoing daily civil penalties until corrections are made.

The visit was complaint-related due to an incident report received on 08/20/2025 about a medication error and a phone call on 08/25/2025 reporting two residents eloping from the memory care unit. One resident was returned to the facility and the other was hospitalized for observation with no injury reported.

The facility was found to have two Type A deficiencies: insufficient staffing in the memory care unit leading to resident elopement, and failure to properly assist a resident with medication resulting in a medication error. Civil penalties totaling $500 were assessed due to repeat violations.

The complaint investigation was substantiated based on the preponderance of evidence for allegations related to facility cleanliness, missing window screens, failure to sanitize after body fluids, and locking of the memory care outdoor space. Other allegations such as presence of insects and administrator qualifications were unsubstantiated.

The investigation substantiated several allegations including failure to keep the facility clean and sanitary, missing and damaged window screens, failure to sanitize after body fluids were found in common areas, and locking of the memory care outdoor space restricting resident access. Some allegations such as presence of insects and administrator qualifications were found unsubstantiated.

The allegation that staff mishandled a resident's medication was substantiated based on records review and interviews. The preponderance of evidence standard was met.

The investigation found that medication refills for a resident were not ordered prior to the resident running out of medication, substantiating the allegation of mishandling medication. The licensee did not comply with regulations regarding timely medication refills, posing a potential health and safety risk.

The complaint investigation was substantiated for the allegation that staff did not maintain resident's hygiene, with evidence including a resident found covered in dried feces and inadequate staffing. The allegation that staff did not provide clean linens was substantiated. The allegation that staff were not properly trained was unsubstantiated.

The investigation substantiated that staff failed to maintain a resident's hygiene, with evidence of a resident found covered in dried feces and inadequate staffing to meet residents' needs. The allegation regarding staff not providing clean linens was substantiated by record review and interviews. The allegation that staff were not properly trained was unsubstantiated based on training records and interviews.

Complaint investigation (15-AS-20250317123152) was conducted and substantiated by observation of an individual not associated with the facility.

The Licensing Program Analyst observed a deficiency where an individual (S4) was not properly associated with the facility, violating California Code of Regulation, Title 22. A deficiency was cited and a plan of correction was required.

The complaint investigation was substantiated for the allegation that staff spoke to residents in an inappropriate manner. Other allegations regarding communicable disease prevention, facility repair, food service, evacuation assistance, and response times were unsubstantiated.

One allegation regarding staff speaking to residents in an inappropriate manner was substantiated, with evidence that staff was removed from cleaning a resident's room after a complaint. Other allegations such as failure to prevent communicable disease spread, facility repair issues, food service adequacy, evacuation assistance, and response times were investigated and found unsubstantiated.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the facility was unsanitary, specifically the memory care side not being cleaned regularly due to lack of housekeeping staff.

The investigation found that the memory care side of the facility was not being cleaned regularly due to lack of housekeeping staff, substantiating the allegation that the facility was unsanitary and not in compliance with cleanliness regulations.

The facility was generally clean, well-maintained, and compliant with safety and infection control standards, including adequate food supply and proper kitchen conditions. However, deficiencies were noted related to hot water temperature controls, with temperatures measured at 128.2 and 96.3 degrees Fahrenheit, outside the required range.

The complaint investigation was substantiated for the allegation of dining furniture not properly cleaned. The allegation regarding utensils not properly cleaned was unsubstantiated. The substantiated deficiency was cited under Title 22 California Code of Regulations 87303(a).

The complaint that dining furniture was not properly cleaned was substantiated due to observation of dried spilled food on a dining chair. The allegation that utensils used for serving meals were not properly cleaned was unsubstantiated after inspection and staff interviews.