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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
071440596
Report Date:
03/26/2024
Date Signed:
03/26/2024 01:45:57 PM
Document Has Been Signed on
03/26/2024 01:45 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. ZAMORA
FACILITY TYPE:
740
ADDRESS:
3053 ROUNDHILL ROAD
TELEPHONE:
(925) 837-0599
CITY:
ALAMO
STATE:
CA
ZIP CODE:
94507
CAPACITY:
6
CENSUS:
1
DATE:
03/26/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Administrator, Ana Breen
TIME COMPLETED:
02:00 PM
NARRATIVE
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On 03/26/2024 at 9:30 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 6 non-ambulatory.
LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are available for residents and 2 bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. The pool is locked and secured. 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 111.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is not a minimum of one week supply of nonperishable and 2-day of perishable foods once expired and spoiled food was discarded. Centrally stored medication and sharps were not locked and inaccessible to residents.
Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 12/29/2023. Emergency Disaster Plan was last reviewed on 10/05/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 02/16/2024.
At 11:00AM, LPA reviewed 1 of 1 residents records. At 11:30AM , LPA reviewed 3 of 3 staff records and 3 of 3 have current first aid training and arenassociated to the facility.
Report continues on LIC 809-C
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
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
11
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:
03/26/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
At 10:00 AM during facility tour LPA observed that food in refrigerator is spoiled and expired. There was spoiled bok choy, tomatoes, bagged salads, uncooked sausages, uncooked corned beef, asparagus, bell peppers, uncooked tri-tip, and uncooked hot dogs among other foods. LPA advised administrator to dispose of the spoiled food as well as the food that was cross contaminated. (repeat violation)
87555(b)(8)
At 10:05 AM during facility tour LPA observed unlocked knife and a pair of scissors in the top oven. Also the sharps cabinet was unlocked and contained a butcher knife. (repeat violation)
87309(a)
At 10:05 AM during facility tour LPA observed the oven to be missing the knobs for function.
At 10:07 AM during facility tour LPA observed animal fecal matter smeared on floor
At 10:14 AM during facility tour LPA observed a disorganized closet with unlocked Combat Roach killing gel.
(repeat violation)
87309(a)
At 10:16 AM during facility tour LPA observed a bottle of Lisinopril 10MG on table in common area. (repeat violation)
87465(h)(2)
At 10:18 AM during facility tour LPA observed a broken latch on sliding door in R1's room. Door was also cushioned with pad used for incontinence. (repeat violation)
87303(a)
At 10:18 AM during facility tour LPA observed layers of cobwebs in R1's bedroom at the top of sliding door.
At 10:20 AM during facility tour LPA observed infestation of ants in laundry room as well as a mildew odor
Report continues on LIC 809-C
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
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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:
03/26/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT CONTINUED:
At 10:25 AM during facility tour LPA observed a screen door with holes and in disrepair
10:00AM -10:29AM Facility was observed unsanitary throughout. Dirt on walls, floors, grease on kitchen appliances, odor throughout facility, surfaces sticky. (repeat violation)
87303(a)
At 11:30 AM during file review LPA observed that R1's physicians report states that they are bedridden and facility is not cleared for bedridden
(
Immediate
$500
civil penalty)
***An Immediate $500 civil penalty is being assessed for fire clearance violation***
*** A $250 civil penalty is being assessed for each repeat violation ($250 X 4)****
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:
03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
3
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Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in R1 being bedridden without the facility being cleared for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to either get the resident re-assesed, or apply for a new fire clearence and notify
CCLD
Type A
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 aboveby having dangerous items unlocked and accesable to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/27/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to remove and lock all items 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
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 inhaving medication in the residents common area on the table which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/27/2024
Plan of Correction
1
2
3
4
Administrator removed and locked away medication during visit.
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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
5
of
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Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(A)
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: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
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 animal fecal matter smeared on the floor and also unsanitized surfaces which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to be in compliance with regulation and notify CCLD.
Type B
Section Cited
CCR
87470(a)(2)(B)
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: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled.
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 buildup of cobwebs and dirt throughout facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to be in compliance with regulation 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
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 by facility being unclean which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to be in compliance with regulation and notify CCLD.
Type B
Section Cited
CCR
87303(a)(1)
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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 aboveby having ants and a mildew odor in laundry room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to be in compliance with regulation 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
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 room 3 having a ripped screen door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to repair or replace screen door 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having spoiled and expired food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/27/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to dispose of spoiled food and restock refrigerator.
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:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
8
of
11
Document Has Been Signed on
03/26/2024 01:45 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:
03/26/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.
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 inhaving the itchen oven in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/09/2024
Plan of Correction
1
2
3
4
By POC date administrator agrees to repair oven 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.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) -28-0517
LICENSING EVALUATOR NAME:
Alona Gomez
TELEPHONE:
510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE:
03/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/26/2024
LIC809
(FAS) - (06/04)
Page:
9
of
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