Inspection Reports for TreVista Senior Living at Concord

The inspection was conducted as an investigation of a complaint regarding medication administration issues at the facility.

The facility failed to provide prescribed medications to residents R1 and R2 due to medication refills not being obtained timely and lack of proper medication orders, posing immediate health and personal rights risks. A repeat violation was cited and a civil penalty was assessed.

Investigation of complaint Control # 15-AS-20250914203842 regarding medication administration failures for residents R1 and R2. Substantiated repeat violation with civil penalty assessed.

Unannounced complaint investigation visit conducted due to allegations including unsanitary resident room conditions, presence of vermin in the facility, and improper eviction of residents.

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 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.

Unannounced proof of correction (POC) visit to verify correction of deficiencies cited during a prior complaint visit on 2025-08-15.

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 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.

The inspection was conducted as a Case Management visit following an incident report of a resident being given the wrong medication and a report of two residents eloping from the memory care unit.

The facility was found to have deficiencies including insufficient staffing leading to resident elopement and failure to properly administer medication. Civil penalties totaling $500 were assessed due to repeat violations.

The visit was complaint-related due to an incident report of wrong medication administration and resident elopement. The deficiencies were substantiated and civil penalties were assessed.

The inspection was a case management visit triggered by multiple elopements of residents from the memory care unit, including incidents on 6/04/2025, 6/15/2025, 6/21/2025, and 8/09/2025.

The facility failed to prevent resident R1 from eloping multiple times due to insufficient staffing, which posed an immediate safety risk. Resident R2 also eloped and suffered a fall requiring hospital evaluation. All egress doors were operational at the time of elopements.

The visit was complaint-related due to multiple elopements by residents R1 and R2. The deficiencies were substantiated with evidence of repeated elopements and an immediate safety risk caused by inadequate staffing.

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-08-01 regarding facility cleanliness, window screens, sanitation after body fluids, and locking of the memory care outdoor space.

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 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.

Unannounced complaint investigation visit conducted due to an allegation that staff mishandled a resident's medication.

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

An unannounced complaint investigation visit was conducted in response to allegations that staff mistreated a resident and mishandled a resident's medications while in care.

The investigation found that the resident had a history of yelling at staff regarding medication handling, and the facility did not lose or miss any medication doses. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff mistreatment and medication mishandling. Evidence did not prove violations occurred.

The inspection visit was an unannounced complaint investigation conducted in response to an allegation that the facility was engaging in punitive acts towards residents in care.

The investigation found that under new management, the facility intended to fill to capacity by placing roommates in memory care rooms that were previously single occupancy. Notices were sent to affected residents. However, there was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint alleged punitive acts towards residents. The investigation included record reviews and interviews with staff and administration. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation visit conducted in response to allegations regarding facility sanitation and food quality.

The investigation found no preponderance of evidence to substantiate the allegations. The food quality concern involved a single incident with a new staff member who was retrained, and sanitation practices were found to be adequate with regular cleaning schedules.

The complaint investigation was unsubstantiated. Allegations included staff not maintaining facility sanitary conditions and not serving residents food of good quality. Interviews and observations did not support these claims.

Unannounced complaint investigation visit conducted due to allegations including staff not maintaining resident's hygiene, not providing clean linens, and improper staff training.

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.

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 visit was an Informal Meeting held via video conference to discuss the Change of Ownership transition for the facility.

The facility is currently operating under the Trevista Concord license despite plans for a name change pending the full Change of Ownership process. The facility intends to operate at full capacity of 160 residents, increasing census from around 110. No deficiencies or violations were cited in this report.

The visit was an unannounced Case Management inspection conducted to assess the facility during a change of ownership process and to follow up on complaint investigations.

The facility was in the process of a change of ownership and was still operating under the Trevista Concord license. The administrator was replaced, and the facility was using a new name on documents, which was not yet authorized. Licensing staff requested documentation to verify the new administrator's credentials.

The inspection was an unannounced Case Management visit conducted to investigate a complaint (15-AS-20250317123152) regarding facility compliance.

The Licensing Program Analyst observed that individual S4 was not associated with the facility, resulting in a cited deficiency related to fingerprints and criminal records requirements for individuals in contact with clients.

Complaint investigation (15-AS-20250317123152) was conducted and substantiated by the observation that S4 was not associated with the facility.

The visit was an unannounced annual inspection conducted to evaluate the facility's compliance with licensing requirements.

The facility was inspected thoroughly with no deficiencies cited. The physical plant, equipment, supplies, and resident records were found to be in compliance with regulations.

The visit was an unannounced Case Management inspection conducted following receipt of a death report for a resident who passed away shortly after moving in.

The report noted that the resident had hypernatremia, acute kidney injury, and was receiving palliative care. No cause of death was listed, and no additional follow-up was needed. It was also noted that the Executive Director no longer works at the facility and the position is actively being recruited.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-11-28 alleging unsafe furniture, unsanitary conditions, improper food storage and preparation, inadequate food portions, and facility disrepair.

The investigation found that the facility was generally clean and food portions were properly maintained and served. A plumbing issue was identified and resolved, and unsafe furniture (a glass table top) was removed. However, there was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The complaint investigation was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred. Allegations included unsafe furniture, unsanitary conditions, improper food storage and preparation, inadequate food portions, and facility disrepair.

Unannounced complaint investigation visit conducted in response to multiple allegations including staff speaking to residents in an inappropriate manner and other facility concerns.

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 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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not give a resident notice of change in level of care.

The investigation found that the facility did notify residents about changes to the level of care point system through multiple notices sent between February 2023 and February 2024. Although concerns were expressed by residents, there was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The complaint alleged that facility staff did not give a resident notice of change in level of care. The investigation found that notices were sent on February 2, 2023, May 1, 2023, and February 1, 2024, explaining changes to the point system and timelines. Residents were informed and concerns were addressed. The allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements for the facility.

The facility was inspected thoroughly with no deficiencies cited. The physical plant, resident rooms, supplies, medication storage, and safety equipment were all found to be in compliance.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2023-05-23 regarding multiple allegations including failure to safeguard resident valuables and medications, facility disrepair, and improper notice for rent increase.

The investigation included interviews and records review, and found that while some allegations may have occurred or are valid, there was not a preponderance of evidence to prove violations. The facility followed regulations regarding medication management and rent increase notice, and repairs were contracted for the facility roof. Therefore, the allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to safeguard resident valuables and medications, facility disrepair, and failure to provide proper notice for rent increase. The facility was found to have followed required procedures and no violations were substantiated.

The visit was conducted as an unannounced complaint investigation following a complaint received on 04/06/2023 alleging that a resident was charged for services not received.

The investigation found that the resident was receiving the level of care paid for, with a noted miscommunication about services provided. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that a resident was charged for services not received. The investigation concluded the allegations were unsubstantiated.

The visit was conducted as a Case Management follow-up to an incident report involving staff hitting a resident.

The Licensing Program Analyst confirmed that the staff involved in the incident had their employment terminated. No additional follow-up was needed at this time.

The visit was complaint-related, following up on an incident report of staff hitting a resident. The complaint was substantiated by the termination of the staff's employment.

The inspection was conducted as an unannounced complaint investigation visit following allegations received on 08/10/2021 regarding the facility's failure to open resident rooms immediately in emergencies and concerns about food quality.

The investigation found that the allegations were unsubstantiated. The master key worked on randomly checked rooms, and staff and residents reported no consistent issues with emergency room access. Food quality was generally observed to be good, with mixed resident and staff opinions but no evidence of raw vegetables being served frequently.

The complaint involved two main allegations: failure to open resident rooms immediately during emergencies and food served not being of good quality. Interviews with residents and staff, inspections of keys and food supplies, and menu reviews were conducted. The complaint was closed as unsubstantiated due to insufficient evidence to prove the alleged violations.

The visit was an unannounced complaint investigation conducted due to an allegation that the facility is unsanitary.

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 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 inspection visit was conducted as an unannounced complaint investigation following a complaint received on 09/29/2022 regarding inoperative residents' toilets.

The investigation found that the facility is timely on repairs reported to maintenance, though delays may occur if parts need to be ordered. There was insufficient evidence to substantiate the allegations, and therefore the complaint was unsubstantiated.

The complaint alleged that residents' toilets were inoperative. The investigation was unannounced and included interviews and document review. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced required 1-year infection control inspection conducted to evaluate the facility's compliance with infection control standards.

The inspection found the facility to be compliant with infection control requirements, including proper PPE use, sufficient food supply, secured storage, and a mitigation plan. No deficiencies were cited during the visit.

An unannounced complaint investigation visit was conducted in response to an allegation that a resident was unlawfully evicted.

The investigation found that the resident was issued a 30-day eviction notice on 02/12/2020 and moved out on 03/30/2020. Although the allegation may have been valid, there was insufficient evidence to substantiate the claim, and the allegation was determined to be unsubstantiated.

The complaint alleged that a resident was unlawfully evicted. The allegation was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced infection control inspection conducted as part of the required 1-year comprehensive inspection.

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 inspection visit was an unannounced complaint investigation triggered by allegations received on 2021-08-10 regarding cleanliness issues at the facility.

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.

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).