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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201139
Report Date: 04/16/2025
Date Signed: 04/16/2025 05:14:02 PM

Document Has Been Signed on 04/16/2025 05:14 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/
DIRECTOR:		MATEL, MARIA TFACILITY TYPE:
740
ADDRESS:1930 LAS COLINAS DR.TELEPHONE:
(925) 522-6145
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 3DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:ROSARIO BOLARDE, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 04/16/2025 at 1:35PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Rosario Bolarde, spoke with Administrator, Maria Matel via telephone, and explained the of the visit. The Administrator arrived at 2:29PM. Administrator holds an Administrator Certificate (#7033531740) that expired on 01/29/2025. 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 five (5) bedrooms, four (4) occupied by residents, one (1) occupied by staff and two (2) 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 xx 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 118.1 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 not tagged for purchased or being serviced. Emergency Disaster Plan was last posted on 04/16/2025. First aid kit was observed to be complete.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/16/2025
NARRATIVE
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Continued from LIC809.

LPAs requested the following documents to be submitted to CCLD by 04/23/2025.

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 2:05pm LPA observed medications in an unlocked cabinet in the garage and staff office
  • At 2:06pm LPA observed washing detergent unlocked located in the garage
  • At 2:12pm LPA observed matches and fire place lighter located in an unlocked drawer located in the kitchen
  • At 3:15pm LPA observed R1 was missing a medical assessment (LIC602)
  • At 3:40pm LPA observed the facility has not conducted fire/disaster drills



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.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/16/2025 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/16/2025 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: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked washing detergent, matches, and a fire place lighter located in the garage and kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to have staff lock washing detergent in the garage by the POC date.
Type A
Section Cited
CCR
87465(h)(2)
(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
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Based on observation, the licensee did not comply with the section cited above by having unlocked medication in the unlocked garage which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Administrator agreed to have staff lock their medications at all times and submit photos of cabinet licked to the department by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/16/2025 at 04:18 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: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical assesment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having a medical assessment for R1 which poses a potential health and safety to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Administrator agreed to provide a copy of R1's medical assessment (LIC-602) to the department by the POC date.
Type B
Section Cited
CCR
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not conducting disaster drills quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator has agreed to conduct a disaster drill and submit a written statement regarding how often disaster drills should be conducted and submit the statement to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 04/16/2025 at 04:48 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: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
This requirement is not met as evidenced by: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a fire extinguisher without purchase receipt or service tag which poses a potential health and safety risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Administrator agrees to submit photos of updated fire extinguisher tag by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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