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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440596
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:35:20 PM


Document Has Been Signed on 11/03/2023 12:35 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:ROUNDHILL CARE HOMES, INC.FACILITY NUMBER:
071440596
ADMINISTRATOR:PEDRO D. ZAMORAFACILITY TYPE:
740
ADDRESS:3053 ROUNDHILL ROADTELEPHONE:
(925) 837-0599
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:6CENSUS: 2DATE:
11/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ana Breen, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 11/03/2023 at 9:30am, Licensing Program Analysts (LPAs) A. Gomez and L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Ana Breen, Administrator, and explained the purpose of the visit.

LPA A Gomez conducted an Annual Inspection on 10/05/2023 and cited facility for the following:

  • 87307(d)(4)Personal Accommodations and Services- LPA observed on today outside deck and inside flooring have been repaired .

LPA A Gomez conducted an Annual Inspection on 10/05/2023 and will recite facility for the following:

  • 87303(a) Care Persons with Dementia- LPAs observed today swimming pool not fenced and locked
  • 87555(b)(8) General Food Service Requirements- LPAs observed today food of poor quality (banna's, apples, uncovered rice in refrigerator...)
  • 87303(a) Maintenance and Operation- LPAs observed the facility today unsanitary and obstructed with items (dust in main living room, clothes piled in laundry room, various items throughout...)
  • 87307(d)(6) Personal Accommodations and Services- LPAs observed roll away bed, toilet snake, a car cover filled with miscellaneous car parts...

continued on LIC 809C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596
VISIT DATE: 11/03/2023
NARRATIVE
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Continued from LIC 809

LPA observed the following deficiency on todays date:
  • At approximately 9:50AM LPAs observed unlocked medication in kitchen.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and appeal rights provided

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2023 12:35 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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By POC date Administrator agrees to have facility common areas sanitary, and laudry room clean. Administrator will submit photo to CCLD.
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Based on observation, the licensee did not comply with the section cited above due to facility being unsanitary which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/20/2023
Section Cited
CCR87555(b)(8)

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(b) The following food service requirements shall apply: (8) All food shall be of good quality...

This requirement is not met as evidenced by:
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By POC date Administrator agrees to discard all food of poor quality and submit photographic proof to CCLD
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Based on observation, the licensee did not comply with the section cited above by having food of poor quality which poses a potential health, safety or personal rights 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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2023 12:35 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
87705(e)

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(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
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By POC date Administrator agrees to install a fence that is in compliance with state and local building codes and submit photographic proof to CCLD
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Based on observation, the licensee did not comply with the section cited above by having an unlocked pool area with a fence shorter than five feet which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/20/2023
Section Cited
CCR87307(d)(6)

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(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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By POC date Administrator agrees to have items in backyard removed or placed in a locked storage and submit photographic proof to CCLD
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Based on observation, the licensee did not comply with the section cited above by having outdoor area obstructed
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/03/2023 12:35 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2023
Section Cited
CCR
87465(h)(2)

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(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.
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LPAs observed Administrator locked away medicine during visit
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Based on observation, the licensee did not comply with the section cited above by having unlocked medication in kitchen which poses an immediate health, safety or personal rights 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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
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