079201139-4-29-2024-15-AS-TSGN-D4T37M-20240429180010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 04/29/2024
Date Signed: 04/29/2024 06:00:19 PM

Document Has Been Signed on 04/29/2024 06:00 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
OAKLAND ASC, 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) 522-6145
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:52 PM
MET WITH:	Christina Federico Caregiver		TIME COMPLETED:	06:00 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 04/29/2024 at 2:52PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Christina Federico, spoke with Administrator, Maria Matel via telephone, and explained the of the visit. The Administrator arrived at 3:52PM. Administrator holds an Administrator Certificate (#6053192740) that expires on. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms, five (5) occupied by residents, one (1) occupied by staff and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 122.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars .There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 02/26/2024. Emergency Disaster Plan was last posted on 02/03/2024. First aid kit was observed to be complete. Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SIMONE SUMMIT CARE HOME	FACILITY NUMBER: 079201139
	VISIT DATE: 04/29/2024

NARRATIVE

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Continued from LIC809.

LPAs requested the following documents to be submitted to CCLD by 05/06/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

LPAs observed the following deficiencies:

At 3:11pm LPA observed medications in an unlocked cabinet in kitchen
At 3:12pm LPA observed scissors and knives in an unlocked drawer in the kitchen

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/29/2024 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SIMONE SUMMIT CARE HOME	FACILITY NUMBER: 079201139
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having Knives and Scissors stored inaccessible to the residents with which poses an immediate health, safety risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Caregiver immediately locked drawer with Knives and Scissors during visit. Deficiency cleared.

Type A

Section Cited

CCR

87705(f)(1)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: 2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having medications stored and inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	caregiver immediately locked cabinet with medications during visit. Deficiency cleared

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: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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