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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:26:51 PM


Document Has Been Signed on 05/12/2022 12:26 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 HOMEFACILITY NUMBER:
079201139
ADMINISTRATOR:MATEL, MARIA TFACILITY TYPE:
740
ADDRESS:1930 LAS COLINAS DR.TELEPHONE:
(925) 513-8978
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
05/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:MATEL, MARIA T, applicant TIME COMPLETED:
12:35 PM
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On 5/12/2022, Licensing Program Analyst (LPA) L. 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, 1 resident is currently at the hospital , there were two staff observed during the visit.

LPA toured the entire premises indoors and outdoors. The facility has 5 bedrThis is in continuation from pre-licensing visit on 3/2022ooms, 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.



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 117.6 degrees Fahrenheit. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit.

Continue LIC809C...
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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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: 05/12/2022
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5 Bedrooms were observed furnished with a bed, bedding, and night stand, 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.

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 applicant 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
LIC809 (FAS) - (06/04)
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