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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 05/22/2023
Date Signed: 05/22/2023 06:13:24 PM

Document Has Been Signed on 05/22/2023 06:13 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:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Aurora Blancio, AdministratorTIME COMPLETED:
06:25 PM
NARRATIVE
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On 5/22/2023 at 2:10PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Aurora Blancio, Administrator, and explained the purpose of the visit. The Administrator certificate is pending and expired 3/26/2023. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) bedrooms and one and one-half (1-1/2) bathrooms. No bodies of water was observed. 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 113.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/20/2022. Emergency Disaster Plan was last posted on 06/22/2022. First aid kit was observed to be complete. Fire drill was last conducted on 01/5/2023.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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: 05/22/2023
NARRATIVE
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Continued from LIC809.

LPAs reviewed three (3) staff files. All three (3) staff did not have first aid or CPR. All four (4) residents' file were reviewed.

LPA observed the following deficiencies:
  • At 2:22PM, LPAs observed refrigerator/freezer and freezer in garage is unsanitary.
  • At 2:25PM, LPAs observed a pair os scissors, allergy medication, a lighter, a bottle of Tylenol, and mucous medication in unlocked kitchen drawer.
  • At 2:30PM, LPAs observed 4 cans of propane, a mattress, a bed frame, a shovel, and a drawer plastic bin in backyard passageway.
  • At 2:45PM, LPAs observed during record review R2 and R4 do not have an current medical assessment.
  • At 2:45PM, LPAs observed during record review none of the residents have a current appraisal needs and services plan.
  • At 3:05PM, LPAs observed during record review none of the staff have first-aid or CPR training.


LPA requested the following documents to be submitted to CCLD by 5/30/2023.
  • 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


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/22/2023 06:13 PM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2023 at 04:58 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
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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4
Based on observation, the licensee did not comply with the section cited above in having a pair of scissors and a lighter accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator agreed to make scissors and lighter inaccessible for residents and submit photo to CCLD by POC date.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(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.

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 medication accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator agreed to make all medication inaccessible for residents and submit photo to CCLD by POC date.
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: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/22/2023 06:13 PM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2023 at 04:58 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having all staff with first-aid certification and at least 1 staff on duty with CPR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Administrator agreed to get all staff first-aid certified and to 1 staff on duty CPR certified and submit certifications to CCLD by POC date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in having current medical assessment for R2 and R4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2023
Plan of Correction
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Administrator agreed to get a current medical assessment for R2 and R4, and submit documents to CCLD by POC date.
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: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2023 06:13 PM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2023 at 04:58 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a current appraisal needs and services plan for all residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Administrator agreed to submit a current appraisal needs and services plan for each resident to CCLD by POC date.
Type B
Section Cited
CCR
87555(b)(29)
(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
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Based on observation, the licensee did not comply with the section cited above in having the refrigerator/freezer and freezer in garage clean which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Administrator agreed to clean refrigerator/freezer and freezer in garage and submit photos to CCLD by POC date.
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: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


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: 05/22/2023
NARRATIVE
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Continued from LIC809C.

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.

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

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/22/2023 06:13 PM - It Cannot Be Edited


Created By: Laura Hall On 05/22/2023 at 05:43 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: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
(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.

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 the outdoor passageways free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2023
Plan of Correction
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Administrator agreed to clear passagway and submit 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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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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