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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440596
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:00:02 PM


Document Has Been Signed on 01/25/2024 01:00 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: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: 3DATE:
01/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ana Breen, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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LPAs K. Nguyen and A. Gomez arrived unannounced to conduct a case management regards to LIC 500. LPA was not able to reach the Administrator. LPAs spoke with Zella Cristobal and explained the purpose of the visit. Zella stating, she was a visitor who came to visit her brother, and when asked if there’s any staff in the facility she stated “NO” only her. Zella was listed as a volunteer on the LIC 500. Later Delze Cristobal arrived. LPA spoke with Administrator, Ana Breen. arrived at 10:35am.

LPAs requesting document to be submit to CCLD by 2/1/24:

-Care plan for all residents

LPAs toured the facility/ Observations at 10:15am:

- Medication was left unlocked inside the First Aid cabinet.

- Knife left out on the kitchen counter on the cutting mat. Knife left out by the sink. Dishwasher was left open knife was observed to be unlocked.

- Chemical was left unlocked in the bathroom cabinet and laundry mat.

- Pool gate was not lock.

- Refusing entry

LPAs observed a deficiency violation which have been cited (see LIC 809d) on 10/05/23. Immediate $500x3 and repeated violation $250 is assess today. Deficiencies, Plan of Corrections, Civil Penalties, Appeal Rights discussed with Ana Breen.

A copy of civil penalty is issue and appeal right provided to Administrator.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 3


Document Has Been Signed on 01/25/2024 01:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87309(a)

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87309 Storage Space:
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients...
(b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above...
This requirement is not met as evidenced by:
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Administrator will review regulation and submit a self-certified stating that AD review and understand the regulation. Administrator will lock all chemical and medicine and submit proof to CCLD by the due date.
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Based on observation, the licensee did not comply with the section cited above by leaving:
- Medication was left unlocked inside the First Aid cabinet.
- Knife left out on the kitchen counter on the cutting mat. Knife left out by the sink. Dishwasher was left open knife was observed to be unlocked.
- Chemical was left unlocked in the bathroom cabinet which posed a potential health, safety or personal rights risk to persons in care.
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Type A
01/26/2024
Section Cited
CCR87705(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 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 an unlocked pool area 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/25/2024 01:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
HSC
1569.32

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1569.32 Spot inspections
Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter.
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LPA went over the regulation with Administrator to provide education to informed AD upon regulation.
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This requirement is not met as evidenced by:
Volunteer staff refused to let LPA in when asked.
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Type A
02/01/2024
Section Cited
HSC1548(c)(3)

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1548 (c)(3)
Civil penalties; regulations setting forth appeal procedures for deficiencies


This requirement is not met as evidenced by:
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Administrator will insure to hire more staff. Administrator will review the regulation and submit a self-certifiy that AD review the regulation to CCLD by POC date.
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LPA confirmed with Zella a voluneer at the facility that there was no staff present during the time LPA arrived.
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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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3