079201139-8-31-2023-15-AS-PWAN-CV8VN7-20230831163440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:34:48 PM

Document Has Been Signed on 08/31/2023 04:34 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
E BAY DELTA AC/SC, 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: 6	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Maria Matel, Administrator Rosario Bolarde Snead, Facility Manager		TIME COMPLETED:	04:45 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 08/31/2023 at 1:20 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregivers. LPA met with Administrator, Maria Matel and explained the purpose of the visit. The facility’s fire clearance was approved for 5 Non Ambulatory and 1 Bedridden. LPA toured facility with Rosario including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 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 101 degrees Fahrenheit in bathroom #1 and 102.3 degrees Fahrenheit in bathroom #2. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed and fully charged. First aid kit was observed. Report continues on 809 C.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SIMONE SUMMIT CARE HOME	FACILITY NUMBER: 079201139
	VISIT DATE: 08/31/2023

NARRATIVE

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At 1:40 PM, LPA reviewed 6 of 6 residents records. At PM, 2:18 PM LPA reviewed 5 of 11 staff records and 5 of 5 have current first aid training and associated to the facility. At 4:00 PM, LPA reviewed a sample of 6 of 6 resident’s medications.

The following deficiency was observed during inspection:
-At approximately 2:50 PM LPA observed a full bed rail in bedroom 2 for R1. Based on record review, R1 did not have a physicians order for the full bed rail.

The following deficiency was observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/21/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

Exit interview conducted and a copy of this report provided along with Appeal rights

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/31/2023 04:34 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SIMONE SUMMIT CARE HOME	FACILITY NUMBER: 079201139
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. (a) Based on the individual's preadmission appraisal, ... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record ... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, LPA observed a full bedrail on R1's bed, LPA did not observe a physician's report for the full bed rail which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Administator will contact R1's physician and obtain a writted order for the full bed rail or replace the full rail with a half rail and submit order to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris Watson	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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