<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
071441131
Report Date:
12/28/2023
Date Signed:
12/28/2023 01:17:18 PM
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
ADMINISTRATOR:
PEDRO D. ZAMORA
FACILITY TYPE:
740
ADDRESS:
22 DARTMOUTH PLACE
TELEPHONE:
(925) 743-0890
CITY:
DANVILLE
STATE:
CA
ZIP CODE:
94526
CAPACITY:
6
CENSUS:
4
DATE:
12/28/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Caregiver, Alexander Fabros
TIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1 year annual inspection on this date starting at 9:00am. Upon arrival, LPA met with Caregiver, Alexander Fabros. Administrator, Ana Breen arrived at 9:30am.
LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 78 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 149.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.
Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/9/2022. First aid kit is complete. Emergency disaster plan updated 12/28/2023.
LPA reviewed 1 of 4 staff records. LPA reviewed 4 of 4 residents’ files. 1 staff not associated to facility.
LPA observed the following deficiencies:
-At 9:32am, LPA observed the laundry room cabinets unlocked with cleaning solutions (fabuloso) and 2 hammers. Administrator locked away items. Deficiency cleared during visit.
-At 9:42 am, LPA observed unlocked medications, scissors, and wire snippers in kitchen area cabinet. LPA observed Administrator remove and lock away all items. Deficiency cleared during visit.
-At 9:50am, LPA observed water temperature is maintained at 149.1 degrees F. Water adjusted to 118.1F
Report continues on 809C
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
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
7
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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
VISIT DATE:
12/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
-At 10:50am, During file review LPA observed R2's file missing the emergency id, appraisal of needs and services, and emergency consent form.
-At 11:30am, During file review LPA observed missing files for staff currently on duty. First aid also missing
-At 11:35am, During file review LPA observed missing files for staff training
-At 11:40am, During file review LPA observed staff not associated to facility.
Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 1/12/2024:
LIC 308 Designation of Administrative Responsibility
Updated LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the hot water temperature measuring at 149.1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2023
Plan of Correction
1
2
3
4
During visit administrator adjusted the water temperature to 118.1 degrees
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having unlocked chemicals and dangerous items which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2023
Plan of Correction
1
2
3
4
During visit administrator locked away all items that posed a risk and danger to residents.
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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having unlocked prescriptions in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
12/29/2023
Plan of Correction
1
2
3
4
During visit Administrator locked away all medications.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not having files for the staff on duty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to create personnell files for all staff and self certify to CCLD.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above innot having staff on duty associated to facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to associate staff to facility and submit proof to 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in not providing training as required to staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date Administrator agrees to update all staff's training and provide proof of completion to CCLD.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above innot having the requried staff trained and certified in first aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to have required staff first aid certified and submit certificates to 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
12/28/2023 01:17 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:
ROUND HILL CARE HOMES, INC.
FACILITY NUMBER:
071441131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
12/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R2's file missing the emerergency id and emergency consent form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to complete residents file and self certify to CCLD.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R2 not having an updated appraisal of needs and services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/12/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to update residents appraisal of needs and services and self certify to 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/28/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7