<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440596
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:40:12 PM


Document Has Been Signed on 10/05/2023 02:40 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: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: 2DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ana Breen, AdministratorTIME COMPLETED:
03:00 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 Analysts (LPAs) A. Gomez and P. Watson conducted an unannounced 1-year Required visit on this date. LPAs met and toured with Administrator, Ana Breen. The Administrator currently holds a certificate(#6051319740) to expire on 2/28/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents and subject to three (3) hospice waivers.

LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms which three (3) bedrooms are occupied by the residents and three (3) bedroom is occupied by staff.A comfortable temperature is maintained at 77 degrees Fahrenheit. LPAs 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 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 2-day of perishable foods and a minimum 7-day non-perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/10/2022. First aid kit was observed to be complete.

Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596
VISIT DATE: 10/05/2023
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 9:55AM LPAs reviewed two (2) staff record files and staff have criminal record clearance and are associated to the facility. 2 of 2 staff have current first aid training. LPAS reviewed two (2) resident's records.

The following deficiencies were observed:

10:25AM LPA's observed moldy and expired food in kitchen fridge and pantry

10:29AM LPA's observed unlocked knives on counter (cleared during visit)

10:30AM LPA's observed the inside of the facility to be cluttered and dusty throughout common areas

10:32AM LPA's observed laundry room piled with clothes and unlocked detergent.

10:44AM LPA's observed oxygen tanks without stands in residents (R1) room with no posted signs.

10:59AM LPA's observed unlocked can of RAID bug spray in residents bathroom under sink.

11:09AM LPA's observed clutter and various items in yard (items include but are not limited to: car parts, rusted box springs, mattresses, tires, and other miscellaneous items)

11:10AM LPA's observed the backyard fence in disrepair (fence located on left side of house)

11:11AM LPA's observed an unlocked pool area with a partial fence that is the incorrect height (fence measured below 5 feet)

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.


Report continues on 809C (2)

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/05/2023 02:40 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by obstructing sliding door fire exit in R1's room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
1
2
3
4
Licensee will remove hospital bed from outside of sliding glass door and submit photographic proof to CCL by POC date
Type A
Section Cited
CCR
87618(b)(3)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements:

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 by retaining portable oxygen tanks without stands in R1's room and empty portable tanks in backyard and not having the approprate oxygen signs posted which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
1
2
3
4
Licensee will have unused portable tanks removed and submit photographic proof to CCL by POC date. Oxygen signs were posted durring visit.
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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 10/05/2023 02:40 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having an unlocked pool area with a fence shorter than five feet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
1
2
3
4
Licensee will cover pool with bolted down tarp or install a fence around pool that locks and is over five feet tall and provide photographic proof to CCL by POC Date
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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 10/05/2023 02:40 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to facility being clutterd throughout common areas inside and outside ( items include but are not limited to: boxes, tires, car parts, miscelaneous items, and debris), dust throughout inside of facility, and uneven flooring inside and outside which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
1
2
3
4
Licencee called haul away company to remove clutter and debris from outside backyard, also agreed to secure and lock away miscelaneous items in shed. Licensee agrees to organize and clean inside of the facility and provide photographic proof of inside and outside to CCL by POC date
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

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 by outside deck being uneven and having loose planks and inside flooring in common areas being uneven which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
1
2
3
4
Licensee will repair adn restructure as needed for ouside deck and will replace inside flooring in the uneven areas and inform CCL of repairs by POC date
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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 10/05/2023 02:40 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
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.

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 by having unlocked raid under residents sink which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
1
2
3
4
Deficencie cleared durring visit. LPA observed administrator lock away RAID.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having moldy and expired food in fridge and pantry which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2023
Plan of Correction
1
2
3
4
Licensee agrees to dispose of all moldy and expired food and provide photographic proof to CCL by POC date.
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-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 5 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: ROUNDHILL CARE HOMES, INC.
FACILITY NUMBER: 071440596
VISIT DATE: 10/05/2023
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
LPA requested the following documents to be submitted to CCLD by 10/12/2023.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance




Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7