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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 07/01/2021
Date Signed: 07/01/2021 06:22:11 PM

Document Has Been Signed on 07/01/2021 06:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW RIVERSHORE CARE HOMEFACILITY NUMBER:
075600075
ADMINISTRATOR:BALANCIO, AURORAFACILITY TYPE:
740
ADDRESS:23 STEELE COURTTELEPHONE:
(925) 458-4321
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
06:30 PM
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On 7/01/2021 at 04:30PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Aurora Balancio, Administrator, and explained the purpose of the visit.

Upon entry, LPA was not screened. LPA observed PPE located on living room table. LPA observed two (2) staff not wearing masks. COVID-19 signs were posted on front door. LPA toured facility including but not limited to common areas, bathroom, bedrooms, backyard, garage, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, PPE, and paper supplies are sufficient.

The following deficiencies were observed:

-On 7/1/2021 at 4:50PM, LPA observed dirty clothing, Lysol disinfectant, and acid for cleaning in the bathroom shower.

-On 7/1/2021 at 5:00PM, LPA observed Clorox bleach, Ajax, Lysol disinfectant in unlocked kitchen cabinet that was located underneath the sink.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075
VISIT DATE: 07/01/2021
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Continued from LIC809.

-On 7/1/2021 at 5:15PM, LPA observed 3 ladders, 2 pair of garden sheers, and a pair of garden hedger accessible in backyard.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/01/2021 06:22 PM - It Cannot Be Edited


Created By: Laura Hall On 07/01/2021 at 05:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having garden tools, ladders, cleaners and disinfectants accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2021
Plan of Correction
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Administrator agreed to replace the lock on the kitchen cabinet, to make all disinfectants and cleaners inaccessible, to remove ladders and garden tools, and make them inaccessible. Administrator will submit a photo of corrections to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2021 06:22 PM - It Cannot Be Edited


Created By: Laura Hall On 07/01/2021 at 06:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having dirty clothing in the bathroom shower which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2021
Plan of Correction
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Adminstrator agreed to remove clothing from bathroom shower, and submit a photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


LIC809 (FAS) - (06/04)
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