079201139-3-2-2022-15-AS-LIBO-CC5VLL-20220302153207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:32:12 PM

Document Has Been Signed on 03/02/2022 03:32 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:	SIMONE SUMMIT CARE HOME		FACILITY NUMBER:	079201139
ADMINISTRATOR:	MATEL, MARIA T		FACILITY TYPE:	740
ADDRESS:	1930 LAS COLINAS DR.		TELEPHONE:	(925) 513-8978
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 6	DATE:	03/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Matel, applicant		TIME COMPLETED:	02:30 PM

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	On 3/2/2022 at 10:10 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted a pre- licensing inspection and met with Applicant Maria Matel. This pre-licensing is a change of ownership from old facility Summit Care Home lic# 079200930. During the visit, LPA observed 4 residents resting inside each of their bedrooms and 2 residents resting in the living room, there are two staff observed during the visit. 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. 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 extinguishers one 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 ambulatory with no bed ridden approval. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and 2 days of perishable foods in stock for six people. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage, preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 106.5 degrees Fahrenheit. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit. Continue LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 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 2

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: SIMONE SUMMIT CARE HOME	FACILITY NUMBER: 079201139
	VISIT DATE: 03/02/2022

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

5 Bedrooms were observed furnished with a bed, bedding, and nightstand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPA observed the first aid kit was complete with manual. All exit doors in the facility are equipped with auditory signals. LPA verified there is an active telephone line in the facility, which is currently operating.

During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPA observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

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

· Pair scissors was observed accessible to dementia residents in care.- cleared

Component III was completed during the pre-licensing visit.

LPA is not recommending facility for license until all deficiencies are cleared from facility 079200930. This Pre-Licensing report will be submitted to the Central Application Branch (CAB) for review. Exit interview conducted with Applicant/Administrator.

Exit interview conducted with applicant Maria Matel and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 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

LIC809 (FAS) - (06/04)

Page: 2 of 2