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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 06/22/2022
Date Signed: 06/22/2022 03:49:19 PM

Document Has Been Signed on 06/22/2022 03:49 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: 4DATE:
06/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
03:55 PM
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On 6/22/2022, at 2:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Administrator, Aurora Balancio, and explained the purpose of the visit.

Facility has the following deficiencies that was not cleared:

87455(b) LPA have not received documents to request a hospice waiver from Administrator after case management visit 6/15/2022

87211(a) LPA had not received documents as requested to report incidents from the Administrator after case management visit on 6/15/2022. Administrator gave LPA both incident reports during today's visit.

Civil Penalties for 87455(b) assessed immediately.

Civil Penalties in the total amount of $600.00 is assessed today for the period of 6/16/2022 to 6/22/2022 for failure to meet POC date for deficiency 87455(b). Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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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