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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:43:23 PM


Document Has Been Signed on 04/27/2023 01:43 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) 522-6145
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Maria Matel, Administrator TIME COMPLETED:
02:00 PM
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On 4/27/2023, Licensing Program Analyst (LPA) Leslie Ibo arrived at the facility unannounced to conduct a case management visit. LPA was at the facility for another reason.

LPA provided technical assistance to Administrator regarding not reporting an unusual incident report regarding facility's physical plant. No resident was affected by this incident.

Administrator stated that she understood the discussion regarding the topic mentioned above.

No citation given today. Exit interview conducted.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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