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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201139
Report Date: 04/24/2025
Date Signed: 04/24/2025 02:01:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250103114847
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: 2DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Maria Matel, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Uncleared adults providing care to residents
Staff are mismanaging residents medication
Staff did not prevent resident from having access to medications
Staff makes inappropriate comments towards residents
Staff did not provide resident with appropriate bedroom accommodations
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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On 04/24/2025 at 12:48PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Maria Matel, Administrator and explained the reason for the visit.


Allegation: Uncleared adults providing care to residents
During the investigation, LPA interviewed Administrator (ADM), during interview, ADM stated staff working at the facility is fingerprint cleared and associated. LPA reviewed the staff schedule, (LIC500), and guardian and revealed all staff named on the LIC500 were fingerprint cleared and associated to the facility.



Continue on LIC9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250103114847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/24/2025
NARRATIVE
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Continued from LIC9099


Allegation: Staff are mismanaging residents’ medication

During investigation, LPA reviewed the resident’s medication administration records (MAR), and a sample of medications and revealed, medications are being administered correctly and the MAR is being documented accurately.

Allegation: Staff did not prevent resident from having access to medications

During the investigation, LPA interviewed staff. S1 revealed during interview that the medicine cabinet are always locked, and keys are inaccessible to the residents in care. LPA observed a cabinet located in the kitchen area with residents’ medication. LPA observed the cabinet to be locked, and medications were inaccessible to residents in care.

Allegation: Staff makes inappropriate comments towards residents

During the investigation, LPA interviewed two (2) residents and two (2) staff members. R1 and R2 stated they have never witnessed any inappropriate comments towards any of the residents, staff at the facility is nice and caring to the residents. During the interview with staff, S1 and S2 stated, staff at the facility treats the residents with respect and dignity.

Continued on LIC9099C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250103114847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/24/2025
NARRATIVE
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Continued from LIC9099C

Allegation: Staff did not provide resident with appropriate bedroom accommodations

During the investigation, LPA toured the facility and observed five (5) bedrooms, four (4) private bedrooms and one (1) shared bedroom. LPA observed all five (5) bedrooms to have proper lighting, bedding, lighting and comfortable for residents in care.

Allegation: Staff are not providing adequate food service to residents

During the investigation, LPA interviewed staff and residents, S1 and S2 stated meals are prepared daily, staff also stated they're open to changing the menu upon residents’ request. Interviews with R1 and R2 revealed, R1 and R2 loves the food provided daily, and staff is open to making meals upon request, if there's something on the menu the residents doesn't want. LPA observed there were a minimum of 7 day of nonperishables and 2 days of perishable foods available for residents in care.

Based upon the information obtained during investigation, the above allegations is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3