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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 05/27/2025
Date Signed: 05/27/2025 06:28:55 PM

Document Has Been Signed on 05/27/2025 06:28 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:NEW RIVERSHORE CARE HOMEFACILITY NUMBER:
075600075
ADMINISTRATOR/
DIRECTOR:		BALANCIO, AURORAFACILITY TYPE:
740
ADDRESS:23 STEELE COURTTELEPHONE:
(925) 458-4321
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
05/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Administrator Aurora Balancio TIME VISIT/
INSPECTION COMPLETED:
06:40 PM
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On 05/27/2025 at 3:25 PM, Licensing Program Analysts (LPAs) Y. Brown and L. Hall conducted an unannounced 1-Year Required inspection. LPAs met with Administrator, Aurora Balancio and explained the purpose of the visit. The Administrator certificate #7000305740 and expires on 03/26/2027. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPAs 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 81 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 121.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. 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 05/19/2025. Emergency Disaster Plan was last posted on 05/01/2025. First aid kit was observed to be complete. Fire drill was last conducted on 03/4/2024.

Continued on LIC809.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075
VISIT DATE: 05/27/2025
NARRATIVE
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Continued from LIC809.

LPAs reviewed four (4) resident files and 3 out of 4 resident files were incomplete. LPAs reviewed (3) staff files and 2 out of 3 staff did not have any training records.

LPA observed the following deficiencies:
  • At 3:42 PM, LPAs observed during record review that R1, R2, and R3 files were incomplete.
  • At 3:47 PM, LPAs observed during record review that R1 and R2 had missing Hospice care plans.
  • At 4:06 PM, LPAs observed during record review that S1, S2, and S3 had missing required training.
  • At 4:21 PM, LPAs observed refrigerator, freezer, and cabinet that contained can and dry goods was unsanitary.
  • At 4:26PM, LPAs observed four (4) trimmers, a bicycle, a treadmill, a shovel, a stationary bicycle, a weight bench, wire plant trellis', and motor scooter in back yard.
  • At 4:27 PM, LPAs observed the master bedroom was missing screens on the patio door and bathroom window.
  • At 4:33 PM, LPAs observed 2 (two) bottles of 409 Multi-surface disinfectant cleaner, 1 (one) Pine cleaner, 2 (two) bottles of bleach Clorox disinfectant, 1 (one) Lysol disinfectant and air freshener in the unlocked bathroom cabinet.


LPA requested the following documents to be submitted to CCLD by 06/03/2025.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (Last page)
  • Liability Insurance

Continue to LIC809C
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075
VISIT DATE: 05/27/2025
NARRATIVE
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Continued from LIC 809C

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, 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.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Yasamin Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2025 06:28 PM - It Cannot Be Edited


Created By: Yasamin Brown On 05/27/2025 at 05:35 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: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that disinfectants and cleaners were in unlocked bathroom cabinet which poses an immediate safety risk to persons in care.
POC Due Date: 05/28/2025
Plan of Correction
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The Administrator agrees to make disinfectants and cleaners inaccessible to residents and submit photo to CCLD by POC date. Administrator locked cabinet containing disinfectants and cleaners. Deficinecy cleared during visit.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2025 06:28 PM - It Cannot Be Edited


Created By: Yasamin Brown On 05/27/2025 at 05:35 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: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the required 20 hours of annual training was missing from 2 (two) staff files which poses a potential safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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The Administrator agreed to obtain and complete training for S2 and S3, and submit certificates to CCLD by POC date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

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 hospice are plans for R2 and R3 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Administrator agreed to obtain a hospice care plan for R2, R3, and submit a copy 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2025 06:28 PM - It Cannot Be Edited


Created By: Yasamin Brown On 05/27/2025 at 05:48 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: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having complete and current records for R1, R2, and R3 which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Administrator agreed to complete records and submit self-certification to CCLD by POC date that the records have been completed.
Type B
Section Cited
CCR
87555(b)(21)
(b) The following food service requirements shall apply:

(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

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 and freezer sanitary which poses a potential health risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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Administrator agreed to clean out freezer and refrigerator 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2025 06:28 PM - It Cannot Be Edited


Created By: Yasamin Brown On 05/27/2025 at 05:53 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: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)(6)
(c) 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 outdoor passageways free of obstruction which poses a potential health and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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2
3
4
Administrator agreed to remove all items in passageways and submit photos to CCLD by POC date.
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

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 window screens in repair on patio and bathroom in master's bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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3
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Administrator agreed to have patio and bathroom screen in master's bedroom repaired 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Yasamin Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2025


LIC809 (FAS) - (06/04)
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