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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200930
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:28:25 PM


Document Has Been Signed on 05/12/2022 12:28 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: 5DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maria Matel, Assistant AdministratorTIME COMPLETED:
01:00 PM
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On 5/11/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with Assistant Administrator Maria Matel . This is in continuation from pre-licensing visit on 3/2/2022.

LPA toured the entire premises indoors and outdoors. The facility has 5 bedrooms, 2 bathrooms including staff bathroom, single story house per facility sketch. All 5 bedrooms are designated for residents. Bedroom #3 is approved for bedridden resident. There is a staff lounge located inside the garage that is empty, per applicant staff can use that If they want to rest or take a break. LPA observed 1 fire extinguisher of which was located in the dining area. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 2/1/2022 with an approval for a total capacity of 6 residents all approved for 5 non-ambulatory and 1 bedridden for room #3.

Component III was completed during the pre-licensing visit on 3/2/2022.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Assistant Administrator Maria Matel and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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