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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440596
Report Date: 02/10/2025
Date Signed: 02/11/2025 08:20:44 AM

Document Has Been Signed on 02/11/2025 08:20 AM - 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/
DIRECTOR:		PEDRO D. ZAMORAFACILITY TYPE:
740
ADDRESS:3053 ROUNDHILL ROADTELEPHONE:
(925) 837-0599
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY: 6CENSUS: 1DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator, Ana BreenTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 2/10/2025 at 9:20 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Ana Breen and explained the purpose of the visit. The facility’s fire clearance was approved for all residents may be non-ambulatory.

LPA toured facility with Ana Breen including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 1 bedrooms are occupied by the residents and 3 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. Pool observed locked and secured. A comfortable temperature is maintained at 68 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 110.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/19/2024. Emergency Disaster Plan was last posted on 02/10/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/15/2025.

At 11am, LPA reviewed 1 residents records. At 11:30 am, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. At 1:00pm, LPA reviewed a sample of resident’s medications.

Report Continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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: 02/10/2025
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPA observed that the facility is cluttered and not sanitary; dust throughout
  • LPA observed a pair of green scissors unlocked
  • LPA observed expired food in the refrigerator and not stored properly; expired broccoli and uncovered open food.
  • LPA observed unlocked medications in the refrigerator



***Civil Penalties issued for repeat violations 3 X $250 ***


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2025:

LIC 500 Personnel Report
Current Administrator’s Certificate


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/11/2025 08:20 AM - It Cannot Be Edited


Created By: Alona Gomez On 02/10/2025 at 12:42 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

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 in having unlocked scissors which poses an immediate safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator locked away the scissors POC clear.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 inhaving unsecured medications in the refridgerator which poses an immediate safety risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
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By POC Administrator agrees to purchace a lockbox for the fridge and secure medications and notify CCLD.
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-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/11/2025 08:20 AM - It Cannot Be Edited


Created By: Alona Gomez On 02/10/2025 at 12:42 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows: 

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 in the facility being unsanitary and cluttered which poses a potential health and personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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By POC Administrator agrees to clean off and de-clutter all surfaces, counters, tables, and accesible areas and notify CCLD
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 in having expired and improperly stored food in the refridgerator which poses a potential health and personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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By POC Administrator agrees to clean, organize and dispose of spoiled/expired items in the refridgerator and notify CCLD.
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-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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