Roundhill Care Homes, Inc.
RCFE
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive assistance with daily living activities such as bathing, dressing, meals, and medication management in a home-like setting. RCFEs are not hospitals or skilled nursing facilities — they do not provide round-the-clock medical care.
3053 Roundhill Road · Alamo, 94507
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 214 California RCFE facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity1thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency9thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Roundhill Care Homes, Inc. scores D. Better than 37% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: bottom 1%. Repeats: top 0%. Frequency: bottom 9%.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_general / small beds (214 facilities).
Citation severity over time
↑ worseningWeighted severity score per month · 24 months
Weighted score (24mo)
64
Last citation
Mar 26
Finding distribution
36 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What training are all staff required to complete?Cited Jan 202422 CCR §87411
All direct-care staff must complete:
- 10 hours initial training within the first four weeks of employment.
- 4 hours annual in-service every year thereafter.
- Administrator certificate from a CDSS-approved program — 80 hours for first-time, 40 hours renewal every 2 years.
Ask on tour: Ask when the last staff training was completed and how it's tracked.
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 071440596
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Roundhill Care Homes, Inc.
Inspections & citations
10
reports on file
38
total deficiencies
14
Type A (actual harm)
4
dementia-care citations
InspectionMarch 23, 2026Type A3 deficiencies
Plain-language summary
During a follow-up visit on March 23, 2026, inspectors found that the facility administrator remained in poor health and unable to perform duties, and observed expired and improperly stored food in the refrigerator, a cluttered and unclean kitchen with odor, and hazardous items including unlocked paint cans and scissors left on the kitchen floor. The facility was cited for these violations and given a deadline to correct them. The administrator and facility were provided notice of appeal rights.
View full inspector notes
On 3/23/2026 at 1:00PM Licensing Program Analyst (LPA) arrived to the facility unannounced to conduct a case management for observations made durring the annual visit on 1/28/2026. LPA met with Administrator, Ana Breen and explained the purpose of the visit. While conducting the annual visit on 1/28/2026 LPA observed that the Licensee/Administrator was not of good health and unable to perform their necessary duties. Backup Administrator stated that their condition was temporary and that they should be in good health by the beginning of March 2026. LPA returned to assess the condition of the Licensee/Administrator and observed that their condition remains the same. While conducting the case management LPA also observed the following deficiencies: THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed expired food in the refrigerator and not stored properly LPA observed kitchen cluttered throughout, and carpets unclean with odor LPA observed unlocked paint cans on the kitchen floor and a pair of scissors in a black holster. 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.
Regulation
(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: This requirement is not…
Inspector finding
Based on observation, the licensee did not comply with the section cited above in the facility being maloudorous, and Kitchen cluttered which poses a potential health and personal rights risk to persons in care.
Regulation
(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:
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having expired and improperly stored food in the refrigerator which poses a potential health and personal rights risk to persons in care.
Regulation
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evide…
Inspector finding
Based on observation, the licensee did not comply with the section cited above in in having accesable paint and scissors in the kitchen which poses an immediate safety risk to persons in care.
Other visitJanuary 28, 2026Type A5 deficiencies
Plain-language summary
During a routine annual inspection on January 28, 2026, inspectors found multiple health and safety problems: the facility was cluttered and had dust and cobwebs throughout, a bathroom had urine on the toilet seat, there was a strong odor, scissors and chemicals were unlocked and accessible, the refrigerator held expired food stored improperly with raw meat dripping onto vegetables and uncovered food, the dining room floor was in disrepair, a toilet seat was broken, and trash was piled in open bags rather than properly contained. The facility was issued civil penalties for repeat violations and was instructed to submit corrected documents and an updated emergency disaster plan by March 3, 2025.
View full inspector notes
On 1/28/2026 at 8:30 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 all residents may be non-ambulatory. LPA toured facility with Ana Breen including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 1 bedrooms are occupied by the residents and 3 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. Pool observed locked and secured. 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 109.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 10/14/2025. LPA is requesting a new emergency disaster plan be drafted. LPA reviewed 1 residents records. LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. Report Continues on LIC809-C 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 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed that the facility is cluttered and not sanitary; dust/cobwebs throughout; bathroom with urine on the toilet seat; Facility is malodorous throughout * LPA observed a pair of grey and orange scissors unlocked in kitchen and chemicals in bathroom * LPA observed expired food in the refrigerator and not stored properly; expired garlic, raw meat dripping on veggies, and uncovered open food.* LPA observed the floor in disrepair in the dining/sitting area.; Toilet seat in bathroom is broken LPA observed trash is not properly being disposed of (Piled on top of trash bin in kitchen in open paper bags) ***Civil Penalties issued for repeat violations 3 X $250 *** Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2025: LIC 500 Personnel Report Change of Administrator Documents Emergency Disaster Plan LIC610E 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.
Regulation
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in in having accesable scissors in the kitchen and cleaning chemicals in the bathroom which poses an immediate safety risk to persons in care. POC Due Date: 02/02/2026 Plan of Correction 1 2 3 4 Facility agrees to conduct an inservice and notify CCLD
Regulation
(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:
Inspector finding
Based on observation, the licensee did not comply with the section cited above in the facility being unsanitary, maloudorous, and cluttered which poses a potential health and personal rights risk to persons in care. POC Due Date: 02/02/2026 Plan of Correction 1 2 3 4 By POC facility agrees to remove all clutter from all areas of the facility, deep clean all surfaces, and insure there is no maloudoros scents and notify CCLD
Regulation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having trash improperly disposed of by stacking it on the waste receptical in the kitchen which poses a potential health and personal rights risk to persons in care. POC Due Date: 02/02/2026 Plan of Correction 1 2 3 4 By POC facility agrees to develop and implement a plan for proper disposal of waste and notify CCLD
Regulation
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in the common area flooring and toilet seat being in disrepair which poses a potential safety and personal rights risk to persons in care. POC Due Date: 02/02/2026 Plan of Correction 1 2 3 4 By POC facility agrees to make repairs and notify CCLD
Regulation
(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.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having expired and improperly stored food in the refridgerator which poses a potential health and personal rights risk to persons in care. POC Due Date: 02/02/2026 Plan of Correction 1 2 3 4 By POC facility agrees to store resident and staff food seperatly and disgard all expired food. Facility also agrees to create a reminder poster of kitchen expectations to be posted on the outside of the refridgerator and not…
Other visitFebruary 10, 2025Type A4 deficiencies
Inspector: Alona Gomez
Plain-language summary
On February 10, 2025, inspectors conducted a routine annual inspection and found several health and safety problems: the facility was cluttered and not sanitary with dust throughout, scissors were left unlocked and accessible, expired food was stored in the refrigerator alongside uncovered open food, and medications were left unlocked in the refrigerator. The facility was issued civil penalties for repeat violations. The facility was required to submit updated documentation and correct these deficiencies by March 3, 2025.
View full inspector notes
On 2/10/2025 at 9:20 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 all residents may be non-ambulatory. LPA toured facility with Ana Breen including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 1 bedrooms are occupied by the residents and 3 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. Pool observed locked and secured. A comfortable temperature is maintained at 68 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 110.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/19/2024. Emergency Disaster Plan was last posted on 02/10/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/15/2025. At 11am, LPA reviewed 1 residents records. At 11:30 am, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. At 1:00pm, LPA reviewed a sample of resident’s medications. Report Continues on LIC809-C 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 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed that the facility is cluttered and not sanitary; dust throughout LPA observed a pair of green scissors unlocked LPA observed expired food in the refrigerator and not stored properly; expired broccoli and uncovered open food. LPA observed unlocked medications in the refrigerator ***Civil Penalties issued for repeat violations 3 X $250 *** Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2025: LIC 500 Personnel Report Current Administrator’s Certificate 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.
Regulation
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having unlocked scissors which poses an immediate safety risk to persons in care. POC Due Date: 02/10/2025 Plan of Correction 1 2 3 4 Administrator locked away the scissors POC clear.
Regulation
(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.
Inspector finding
Based on observation, the licensee did not comply with the section cited above inhaving unsecured medications in the refridgerator which poses an immediate safety risk to persons in care. POC Due Date: 02/11/2025 Plan of Correction 1 2 3 4 By POC Administrator agrees to purchace a lockbox for the fridge and secure medications and notify CCLD.
Regulation
(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:
Inspector finding
Based on observation, the licensee did not comply with the section cited above in the facility being unsanitary and cluttered which poses a potential health and personal rights risk to persons in care. POC Due Date: 03/03/2025 Plan of Correction 1 2 3 4 By POC Administrator agrees to clean off and de-clutter all surfaces, counters, tables, and accesible areas and notify CCLD
Regulation
(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.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having expired and improperly stored food in the refridgerator which poses a potential health and personal rights risk to persons in care. POC Due Date: 03/03/2025 Plan of Correction 1 2 3 4 By POC Administrator agrees to clean, organize and dispose of spoiled/expired items in the refridgerator and notify CCLD.
InspectionNovember 20, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
On November 20, 2024, the state made an unannounced visit to deliver a final report on a complaint that had been investigated at the facility. All allegations in the complaint were found to be unsubstantiated, and no violations were cited.
View full inspector notes
On 11/20/2024 at 4:02PM Licensing Program Analyst (LPA) arrived to the facility unannounced to deliver an Amended report for complaint 15-AS-20240502154143 . LPA met with Administrator, Ana Breen and explained the purpose of the visit. LPA delivered the amended report. All Allegations went Unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitMarch 26, 2024Type A10 deficiencies
Inspector: Alona Gomez
Plain-language summary
A routine annual inspection on March 26, 2024 found multiple violations, including spoiled food in the refrigerator, unlocked medication and sharp objects (knives and scissors) accessible to residents, animal fecal matter on the floor, pest infestation, and overall unsanitary conditions throughout the facility with dirt on walls and sticky surfaces. The facility was also operating with a resident who is bedridden despite not being licensed to care for bedridden residents. The facility was assessed civil penalties totaling $1,250 for these violations, several of which were repeat findings from prior inspections.
View full inspector notes
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 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 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 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 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.
Regulation
(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 fi…
Inspector finding
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
Regulation
(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.
Inspector finding
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.
Regulation
(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.
Inspector finding
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.
Regulation
(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 …
Inspector finding
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.
Regulation
(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 …
Inspector finding
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.
Regulation
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.
Inspector finding
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.
Regulation
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.
Inspector finding
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.
Regulation
(c) All window screens shall be clean and maintained in good repair.
Inspector finding
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.
Regulation
(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.
Inspector finding
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.
Regulation
(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.
Inspector finding
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.
Other visitJanuary 25, 2024Type A2 deficiencies
Inspector: Kelly Nguyen
Plain-language summary
During an unannounced case management visit, inspectors found multiple safety hazards left unsecured: medications in an unlocked cabinet, knives on the kitchen counter and by the sink, chemicals in unlocked bathroom and laundry cabinets, and an unlocked pool gate. These same safety issues had been cited previously in October 2023, and the facility was assessed civil penalties for the repeated violations. The administrator was provided with documentation of the deficiencies and information about appeal rights.
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LPAs K. Nguyen and A. Gomez arrived unannounced to conduct a case management regards to LIC 500. LPA was not able to reach the Administrator. LPAs spoke with Zella Cristobal and explained the purpose of the visit. Zella stating, she was a visitor who came to visit her brother, and when asked if there’s any staff in the facility she stated “NO” only her. Zella was listed as a volunteer on the LIC 500. Later Delze Cristobal arrived. LPA spoke with Administrator, Ana Breen. arrived at 10:35am. LPAs requesting document to be submit to CCLD by 2/1/24: -Care plan for all residents LPAs toured the facility/ Observations at 10:15am: - Medication was left unlocked inside the First Aid cabinet. - Knife left out on the kitchen counter on the cutting mat. Knife left out by the sink. Dishwasher was left open knife was observed to be unlocked. - Chemical was left unlocked in the bathroom cabinet and laundry mat. - Pool gate was not lock. - Refusing entry LPAs observed a deficiency violation which have been cited (see LIC 809d) on 10/05/23. Immediate $500x3 and repeated violation $250 is assess today. Deficiencies, Plan of Corrections, Civil Penalties, Appeal Rights discussed with Ana Breen. A copy of civil penalty is issue and appeal right provided to Administrator.
Regulation
87309 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... (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above... Thi…
Inspector finding
Based on observation, the licensee did not comply with the section cited above by leaving: - Medication was left unlocked inside the First Aid cabinet. - Knife left out on the kitchen counter on the cutting mat. Knife left out by the sink. Dishwasher was left open knife was observed to be unlocked. - Chemical was left unlocked in the bathroom cabinet which posed a potential health, safety or personal rights risk to persons in care.
Regulation
(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:
Inspector finding
Based on observation, the licensee did not comply with the section cited above by having an unlocked pool area which poses a potential health, safety or personal rights risk to persons in care.
InspectionNovember 30, 2023No deficiencies
Inspector: Alona Gomez
Plain-language summary
This was a follow-up inspection on November 30, 2023 to confirm that the facility had fixed problems found in a previous visit. Inspectors verified that the swimming pool was properly fenced and locked, food was stored and labeled correctly, the facility and grounds were clean and well-maintained, and walkways were clear of obstacles. All previously cited issues were found to be corrected.
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On 11/30/2023 at 9:30am, Licensing Program Analysts (LPAs) A. Gomez and L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Ana Breen, Administrator, and explained the purpose of the visit. LPA A Gomez conducted a POC visit on 11/03/2023 and cited facility for the following: · 87303(a) Care Persons with Dementia- LPAs observed today swimming pool fenced and locked · 87555(b)(8) General Food Service Requirements- LPAs observed today food of good quality and labeled appropriately. · 87303(a) Maintenance and Operation- LPAs observed the facility to be clean and in good repair · 87307(d)(6) Personal Accommodations and Services- LPAs observed the facility and yard to be free of obstruction LPAs observed that all deficiencies are now clear. Exit interview conducted and a copy of this report provided
InspectionNovember 3, 2023Type A5 deficiencies
Inspector: Alona Gomez
Plain-language summary
During a follow-up inspection on November 3, 2023, inspectors found that while some repairs to the deck and flooring had been completed, the facility still had multiple unresolved problems: the swimming pool was not fenced and locked, food quality was poor with uncovered rice and spoiled fruit in the kitchen, medication was left unlocked, and the facility had clutter and dust throughout common areas including clothes piled in the laundry room and miscellaneous items stored in resident areas. The facility was given time to correct these deficiencies, with the warning that failure to do so within 12 months could result in penalties.
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On 11/03/2023 at 9:30am, Licensing Program Analysts (LPAs) A. Gomez and L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Ana Breen, Administrator, and explained the purpose of the visit. LPA A Gomez conducted an Annual Inspection on 10/05/2023 and cited facility for the following: 87307(d)(4) Personal Accommodations and Services - LPA observed on today outside deck and inside flooring have been repaired . LPA A Gomez conducted an Annual Inspection on 10/05/2023 and will recite facility for the following: 87303(a) Care Persons with Dementia- LPAs observed today swimming pool not fenced and locked 87555(b)(8) General Food Service Requirements- LPAs observed today food of poor quality (banna's, apples, uncovered rice in refrigerator...) 87303(a) Maintenance and Operation- LPAs observed the facility today unsanitary and obstructed with items (dust in main living room, clothes piled in laundry room, various items throughout...) 87307(d)(6) Personal Accommodations and Services- LPAs observed roll away bed, toilet snake, a car cover filled with miscellaneous car parts... continued on LIC 809C 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 Continued from LIC 809 LPA observed the following deficiency on todays date: At approximately 9:50AM LPAs observed unlocked medication in kitchen. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided
Regulation
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:
Inspector finding
Based on observation, the licensee did not comply with the section cited above due to facility being unsanitary which poses a potential health, safety or personal rights risk to persons in care.
Regulation
(b) The following food service requirements shall apply: (8) All food shall be of good quality... This requirement is not met as evidenced by:
Inspector finding
Based on observation, the licensee did not comply with the section cited above by having food of poor quality which poses a potential health, safety or personal rights risk to persons in care.
Regulation
(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:
Inspector finding
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 a potential health, safety or personal rights risk to persons in care.
Regulation
(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
Inspector finding
Based on observation, the licensee did not comply with the section cited above by having outdoor area obstructed
Regulation
(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.
Inspector finding
Based on observation, the licensee did not comply with the section cited above by having unlocked medication in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
InspectionOctober 5, 2023Type A7 deficiencies
Inspector: Alona Gomez
Plain-language summary
During a routine yearly inspection, inspectors found multiple safety and sanitation issues: moldy and expired food in the kitchen, unlocked knives on counters, unlocked cleaning chemicals and bug spray in bathrooms, oxygen tanks without proper safety stands or warning signs in a resident's room, and an unlocked pool area with a fence that was too short. The facility also had clutter throughout common areas and yard, including car parts and mattresses, along with a damaged backyard fence. The facility was given a deadline to submit corrections for these deficiencies.
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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 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) 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 .
Regulation
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
Inspector finding
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
Regulation
(3) Ensuring that the use of oxygen equipment meets the following requirements:
Inspector finding
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 v…
Regulation
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.
Inspector finding
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
Regulation
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.
Inspector finding
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 …
Regulation
(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.
Inspector finding
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
Regulation
(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.
Inspector finding
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.
Regulation
(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.
Inspector finding
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.
ComplaintMarch 21, 2022Type A2 deficiencies
Inspector: Lizette Francisco
Plain-language summary
Inspectors visited this facility on March 21, 2022 to check infection control practices and found the facility had good screening procedures, food supplies, and staff hygiene, but identified three problems: over-the-counter medications were left unlocked on a kitchen counter (which the administrator locked away during the visit), a side gate was in disrepair, and furniture and items were cluttered on the deck. The facility was told to correct these issues by a specified deadline or face additional penalties.
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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.
Regulation
(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.
Inspector finding
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 1 2 3 4 Deficiency cleared during visit. LPA observed Administrator removed over the counter medications and locked it away in kitchen cabinet.
Regulation
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.
Inspector finding
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 1 2 3 4 Administrator agrees to repair side gate and remove all random items on deck and submit a photo to CCL by POC date.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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