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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200930
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:13:26 PM


Document Has Been Signed on 03/02/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SUMMIT CARE HOMEFACILITY NUMBER:
079200930
ADMINISTRATOR:QUISMORIO, HERMINIAFACILITY TYPE:
740
ADDRESS:1930 LAS COLINAS DRIVETELEPHONE:
(925) 998-9365
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
03/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Herminia Quismorio, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 3/2/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with S3 . LPA called Administrator Herminia Quismorio, Administrator arrived 11:50PM, LPA also called applicant Maria Matel, applicant arrived 11:00AM explained the purpose of the visit.

LPA observed the following during the inspection:

· S4 was not associated to the facility - cleared

· Unlocked medications accessible to residents in care - cleared

· LPA observed R3 is bedridden however, facility does not have bedridden clearance

· Scissors was observed accessible to dementia residents in care.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.



A civil penalties is being assessed today.

Exit interview conducted. Appeal Rights and a copy of this report was provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/02/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SUMMIT CARE HOME
FACILITY NUMBER: 079200930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited

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87202 Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons...(2) Bedridden persons
This requirement is not met as evidence by:
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Based on observation and interviews, Licensee failed to obtain fire clearance for bedridden resident. LPA observed R3 is bedridden. However, facility does not have bedridden clearance which poses an immediate health and safety risk to residents in care.
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A civil penalty of $500.00, is being assessed today.
Type A
03/02/2022
Section Cited

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Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by:
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Based on observation the licensee did not comply with the section cited above in at 10:29 AM LPA observed unlocked medications accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/02/2022 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SUMMIT CARE HOME
FACILITY NUMBER: 079200930

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidence by:
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Based on observation, unlocked scissors was observed accessible to dementia residents in care which possess immediate health and safety to residents in care.
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Type B
03/03/2022
Section Cited

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(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility.
This requirement was not met as evidenced by
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Based on interview and records review, S4 is not associated to the facility which posed a potential health & safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3