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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201139
Report Date:
03/02/2022
Date Signed:
03/02/2022 03:32:58 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:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:30 PM
MET WITH:
Maria Matel, Applicant
TIME COMPLETED:
04:00 PM
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Component III was discussed with Applicant Maria Matel, she acknowledge her understanding of all the component III topic.
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)
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