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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441131
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:09:29 PM


Document Has Been Signed on 01/25/2024 01:09 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. ZAMORAFACILITY TYPE:
740
ADDRESS:22 DARTMOUTH PLACETELEPHONE:
(925) 743-0890
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 4DATE:
01/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Ana BreenTIME COMPLETED:
01:15 PM
NARRATIVE
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On 1/25/2024 at 8:00am, Licensing Program Analysts (LPAs) A. Gomez and K. Nguyen arrived unannounced to conduct proof of correction (POC) visit. LPA met with Ana Breen, Administrator, and explained the purpose of the visit.

LPA A Gomez conducted an Annual Inspection on 12/28/2023 and cited facility for the following:

  • 87412(a) Personnel Records- During POC visit LPA observed that all staff files are now complete. Deficiency cleared.

LPA A Gomez conducted an Annual Inspection on 12/28/2023 and will recite facility for the following:

  • 87309(a)(1) Storage Space - LPAs observed today unlocked hammer and wire snippers in laundry room. A $250 civil penalty is being assessed today for a repeat violation in a 12 month period.


The following deficiencies were observed during POC Visit today:
  • LPA observed excessive flies in kitchen and throughout the facility.


report continues on LIC 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 4


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: 01/25/2024
NARRATIVE
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A $250.00 civil penalty is assessed on this day.

The following deficiency observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. LIC421F, Appeal Rights, and a copy of this report provided.

continued on LIC 809C

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

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 01/25/2024 01:09 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87309(a)(1)

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(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:
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By POC date administrator agrees to insure that all dangerous items are locked away and self certify to CCLD.
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Based on observation, the licensee did not comply with the section cited above in having unlocked dangerous items which poses an immediate health, safety or personal rights risk to persons in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/25/2024 01:09 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2024
Section Cited
CCR
80076(a)(17)

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(a) In facilities providing meals to clients, the following shall apply: (17) All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be taken to keep all such areas free of rodents, and other vermin.

This requirement is not met as evidenced by:
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By POC date administrator agrees to get rid of the flies and self submit to CCLD.
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Based on observation, the licensee did not comply with the section cited above by having excessive flies flying around the kitchen and home which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4