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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440596
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:51:16 AM


Document Has Been Signed on 03/21/2022 11:51 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
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:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Ana Villacarlos, AdministratorTIME COMPLETED:
12:05 PM
NARRATIVE
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On 3/21/2022 at 10:25 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Ana Villacarlos and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility maintains a copy of mitigation plan.
LPAs observed the following deficiencies
  • At 10:35 AM, LPAs observed unlocked over the counter medications on kitchen counter. Administrator corrected deficiency during visit. LPAs observed Administrator locked it away.
  • At 10:40 AM, LPAs observed side gate is in disrepair.
  • At 10:41 AM, LPAs observed a cluttered of random furniture and items are being stored on the deck.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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


Document Has Been Signed on 03/21/2022 11:51 AM - 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: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Licensee did not comply with the regulation cited above. LPAs observed unlocked over the counter medication in the kitchen counter which poses an immdiate health and safety risk to persons in care.
POC Due Date: 03/22/2022
Plan of Correction
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Deficiency cleared during visit. LPA observed Administrator removed over the counter medications and locked it away in kitchen cabinet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 03/21/2022 11:51 AM - 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: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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
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Based on LPAs observation, the licensee did not comply with the section cited above. LPAs observed side gate is in disrepair. In addition, LPAs observed a clutter of random items is being stored on deck which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Administrator agrees to repair side gate and remove all random items on deck and submit a photo to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7