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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:45:43 PM

Document Has Been Signed on 01/09/2025 04:45 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 HOMEFACILITY NUMBER:
079201139
ADMINISTRATOR/
DIRECTOR:		MATEL, MARIA TFACILITY TYPE:
740
ADDRESS:1930 LAS COLINAS DR.TELEPHONE:
(925) 522-6145
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:03 PM
MET WITH:Maria Mate,AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 01/09/2025 at 12:30PM Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Maria Matel.

While LPA T.Syess-Gibson was conducting a complaint investigation (15-AS-20250103114847) on 01/09/2025. During file review LPA observed three (3) out of five (5) staff members were missing health screenings.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/09/2025 04:45 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/09/2025 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SIMONE SUMMIT CARE HOME
FACILITY NUMBER: 079201139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2025
Section Cited
CCR
87411(f)

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87411 Personnel Requirements – General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, health. Personnel with evidence of physical illness or emotional instability
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Administrator has agreed to obtain health screening for S1,S2 and S5 and submit a copy of health screening to CCLD by POC date.
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 performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above by not having health screening documents for three(3) out of five (5) staff members which poses a potential health and safety risk to persons in care.
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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
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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