079200930-4-27-2023-15-AS-KHOS-CRFP8Y-20230502110619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200930
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:01:24 PM

Substantiated

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
11/22/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211122105158

FACILITY NAME:	SUMMIT CARE HOME		FACILITY NUMBER:	079200930
ADMINISTRATOR:	QUISMORIO, HERMINIA		FACILITY TYPE:	740
ADDRESS:	1930 LAS COLINAS DRIVE		TELEPHONE:	(925) 998-9365
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	0	CENSUS: 5	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Matel, Administrator from Simone-Summit (new owner)		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident's records were not made available to responsible person

INVESTIGATION FINDINGS:

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On 4/27/2023 at 9:00 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegations above. LPA met with new licensee Maria Matel LPA explained the purpose of the visit. At around 11:00AM, former licensee Herminia Quismorio arrived at the facility.

During the investigation, LPA reviewed documents such as but not limited to, incident reports. LPA conducted staff and residents’ interview. LPA requested R1’s file from new licensee and former licensee, however the file was not available.

Allegation: Resident's records were not made available to responsible person

Based on records review, LPA requested file for new licensee Maria Matel and former licensee Herminia Quismorio, however, staff could not find the file and resident's (R1) file was not available.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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 5

Control Number 15-AS-20211122105158

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: SUMMIT CARE HOME	FACILITY NUMBER: 079200930
	VISIT DATE: 04/27/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20211122105158

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: SUMMIT CARE HOME	FACILITY NUMBER: 079200930
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/05/2023 Section Cited CCR 87506(e)	1 2 3 4 5 6 7	Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requierement was not met as evidence by:	1 2 3 4 5 6 7	Facility do not need POC, this license was closed.
	8 9 10 11 12 13 14	-Based on interviews, the licensee did not comply with the section above for not keeping/retaining R1's record which poses potential personal rights risk to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
11/22/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211122105158

FACILITY NAME:	SUMMIT CARE HOME		FACILITY NUMBER:	079200930
ADMINISTRATOR:	QUISMORIO, HERMINIA		FACILITY TYPE:	740
ADDRESS:	1930 LAS COLINAS DRIVE		TELEPHONE:	(925) 998-9365
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	0	CENSUS: 5	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maria Matel, Administrator from Simone-Summit (new owner)		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not seek timely medical care for resident
Staff did not properly manage resident's incontinence care resulting in infections
Staff talked inappropriately to resident
Staff did not inform resident's responsible person of resident's incident
Staff did not follow resident's modified diet

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20211122105158

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: SUMMIT CARE HOME	FACILITY NUMBER: 079200930
	VISIT DATE: 04/27/2023

NARRATIVE

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Allegation: Staff did not seek timely medical care for resident

Staff interview revealed that they were trained from Administrator that if they notice change of resident’s condition or resident fell, they need to call 9-1-1. Staff stated that when they noticed R1's changed of condition they called 9-1-1 and informed responsible party. LPA attempted to interview one resident (R2) who was still at the facility under new management, however R2 is non-verbal.

Allegation: Staff did not properly manage resident's incontinence care resulting in infections

Staff interviews reveal that R1 was not wearing incontinence care product but rather used urinal to urinate. Although the new Administrator Maria M. stated that R1 had infection, however LPA do not have evidence that it is from mismanagement of resident's (R1) incontinence. Staff stated that R1 called the staff after he used the urinal then staff assisted R1 to discard his urine. LPA was not able to interview R1 and R2.

Allegation: Staff talked inappropriately to resident

Based on staff interview staff stated that they have not witnessed or heard any staff acting inappropriate behavior towards clients/residents in care and staff denied observing any staff yelling at the clients/residents in care. LPA was not able to interview R1 and R2.

Allegation: Staff did not inform resident's responsible person of resident's incident

Based on staff interview, when R1 had to go to the emergency room, the staff called R1’s responsible party as soon as they can to inform regarding R1’s condition.

Allegation: Staff did not follow resident's modified diet

Based on staff interview, R1 was on soft diet, the staff provided soft diet food for the resident (R1). Staff stated that R1’s family used to bring food for the resident (R1), some of them are microwavable food and family insisted to feed the R1 with those food.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5