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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
071441131
Report Date:
12/30/2024
Date Signed:
12/30/2024 01:23:37 PM
Document Has Been Signed on
12/30/2024 01:23 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/
DIRECTOR:
PEDRO D. ZAMORA
FACILITY TYPE:
740
ADDRESS:
22 DARTMOUTH PLACE
TELEPHONE:
(925) 743-0890
CITY:
DANVILLE
STATE:
CA
ZIP CODE:
94526
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
4
DATE:
12/30/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:
Backup Administrator, Ana Breen
TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 12/30/2024 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Ana Breen and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory with a hospice waiver for 3.
LPA toured facility with Ana including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 4 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 133.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/20/2024. Emergency Disaster Plan was last posted on 1/02/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted in September 2024.
At 10:41am, LPA reviewed 4 residents records. At 11:00 am, LPA reviewed 3 staff records and 2 of 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.
Report Continues on LIC809-C
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
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
8
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:
12/30/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 9:39AM LPA observed bags of trash in the backyard on the deck.
At 9:41AM LPA observed expired canned goods.
At 9:44AM LPA observed that food is improperly stored in fridge and freezer; open meat and uncovered residents food
At 9:44AM LPA observed kitchen surfaces to be unclean and layered with grease and oils
At 9:47AM LPA observed a Lighter in a drawer under the oven as well an unsecured butchers knife by the kitchen sink.
At 9:48AM LPA observed cobwebs built up in the residents living room
At 9:56AM LPA observed broken drawers throughout the facility off the tracks or missing handles
At 9:57AM LPA observed unclean surfaces throughout the facility
At 11:04AM LPA observed the hot water at 133.7 degrees F.
***Civil Penalty Assessed for repeat violations $250 X 2
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/15/2025:
LIC 308 Designation of Administrative Responsibility
Updated Administrator Documents
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.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
12/30/2024 01:23 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:
12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
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2
3
4
Based on observation, the licensee did not comply with the section cited above in the hot water measuring over 120 degrees F which poses an immediate safety risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
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By POC facility agrees to adjust the water in accordance with regulations and notify CCLD
Section Cited
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 a knife and lighter accessible which poses an immediate safety risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
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2
3
4
Dangerous items secured POC Clear.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
12/30/2024 01:23 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:
12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the facility having unclean surfaces throughout which poses a potential health, and safety risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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2
3
4
By POC facility agrees to deep clean the whole facility and notify CCLD
Section Cited
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents.
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 storing garbage on the deck that is for clients use which posed a potential health, safety and personal rights risk to persons in care.
POC Due Date:
12/30/2024
Plan of Correction
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2
3
4
Garbage removed and disposed of POC Clear.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
12/30/2024 01:23 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:
12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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 broken cabinets and drawers throughout facility which poses a potential safety and personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
1
2
3
4
By POC Facility agrees to make all necessary repairs and notify CCLD
Section Cited
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having expired canned goods which poses a potential health and safety risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
1
2
3
4
By POC Facility agrees to remove expired food and replace with food of good quality.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
12/30/2024 01:23 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:
12/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
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 not storing food properly which poses a potential health and safety risk to persons in care.
POC Due Date:
12/31/2024
Plan of Correction
1
2
3
4
By POC Facility agrees to dispose of improperly stored food and provide a training to staff and notify CCLD.
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.
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
Alona Gomez
TELEPHONE:
510-239-1306
DATE:
12/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/30/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8