Simone Summit Care Home

Type of visit: Required - 1 Year

On 05/20/2026 at 10:00PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Assistant Hannah Armamento, LPA 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 01/29/2027. 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 70 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 117.3 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. Continued on LIC809C. 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 02/01/2026. First aid kit was observed to be complete. LPAs requested the following documents to be submitted to CCLD by 05/28/2026. 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 10:30am LPA observed a staff member working not finger printed. At 11:22am LPA observed unlocked medication in a drawer located in the kitchen drawer. At 11:31am LPA observed 2 shovels located in the backyard. 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. Civil Penalties for 87355(d)(3) in the amount of $200.00 assessed immediately for the period 05/19/2026 to 05/20/2026. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, May 20, 2026

Allegation investigated: Neglect/lack of supervision

On 10/30/2025 at 1:47PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. LPA met with Maria Matel, Administrator, and explained the reason for the visit. Allegation:Neglect/lack of supervision During the investigation, LPA interviewed resident (R1), ADM and staff (S1), LPA also obtained documents. During interview with (R1), it was revealed that ADM daughter has come into R1’s room to inquire what the R1 needs when R1 presses the call button followed by staff. ADM's daughter hasn’t provided care for R1. Continue on LIC9099C.... Unsubstantiated Continued from LIC9099 During interview with ADM, it was revealed that ADM daughter isn’t of age to be left alone and that there is always a staff member at the facility with R1. Interview with staff (S1), revealed, ADM has never left her daughter alone at facility with R1, that there have been times when staff have been in the backyard and daughter runs in R1’s room to see what R1 needs after call button is pressed and that staff is behind ADM daughter upon entering R1’s room. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation 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 report was given.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 15-AS-20250905154824

Type of visit: Case Management - Deficiencies

On 10/30/2025, while LPA T. Syess-Gibson was conducting a complaint investigation 15-AS-20250905154824 on 10/15/2025. During interview and record review LPA observed R1’s file was missing documents. LPA requested Home Health (HH) plan of care for R1. Administrator stated that she has to contact the HH agency for care plan, does not have a plan of care at the facility. LPA requested the HH plan of care and care notes be emailed by 11/06/2025. 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 providedthe state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87643(a) · Plan of correction due date: Nov 6, 2025

(a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not having a care plan for resident who require use of an indwelling urinary catheter, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: Administrator agreed to obtain a plan of care from appropriate Home Health Agencies and email CCLD copies of plan by POC date.

Allegation investigated: 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

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 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 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.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 15-AS-20250103114847

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Apr 16, 2025

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

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 tour of facility LPA observed storage room in garage have been remodeled and turned into two(2) lounge rooms with one(1) bed and one (1) futon. Facility did not have permit or notify CCLD. Administrator stated the beds are for staff to sleep. 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.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Jan 23, 2025

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in notifying CCLD of any alterations which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Administrator agreed to remove wall and beds or submit a LIC200 and updated facility sketch to CCLD by POC date.

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Jan 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Jan 16, 2025

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 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.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Administrator has agreed to obtain health screening for S1,S2 and S5 and submit a copy of health screening to CCLD by POC date.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Apr 29, 2024