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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 06/15/2022
Date Signed: 06/15/2022 07:42:01 PM

Document Has Been Signed on 06/15/2022 07:42 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:
06/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
07:40 PM
NARRATIVE
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On 6/15/2022 at 6:30PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding a request of hospice services to CCLD on 6/10/2022. LPA met with Administrator, Aurora Balancio and explained the purpose of the visit.

An email was received via email to LPA L. Hall on 6/10/2022, requesting a hospice waiver for one (1). LPA telephoned Staff 1 (S1) to request more documents and inquire on the resident that will be receiving hospice services. S1 stated that the resident has been receiving hospice services for two (2) weeks and the facility has another resident that has been receiving hospice services for two (2) months. S1 did not obtain a hospice care waiver for R1 or R2 from the Department before retaining residents at the facility.

While LPA was conducting the annual inspection on 6/15/2022, LPA was informed that two (2) residents R3 and R4 had tested positive for COVID. S1 stated she did not report incident to CCLD.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

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: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/15/2022 07:42 PM - It Cannot Be Edited


Created By: Laura Hall On 06/15/2022 at 06:43 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: 06/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited
CCR
87211(a)(2)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (2) Occurrences, such as epidemic outbreaks...which threaten the welfare, safety or health of residents...This requirement was not met as evidence by:
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Administrator agreed to submit LIC624 for both residents to CCLD by POC date.
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Based on LPAs record review and interview, licensee did not comply with the section cited above in reporting to COVID residents to CCLD, which poses a health and safety risk to persons in care.
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Type A
06/16/2022
Section Cited
CCR87455(b)(8)

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87455 (b) The following persons may be accepted or retained in the facility: (8)Persons who have been diagnosed as terminally ill and who have obtained the services of hospice... This requirement was not met as evidence by:
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Administrator agreed to submit a request for a hospice waiver for 2 residents from CCLD by POC date.
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Based on LPAs interview and record review, Licensee did not comply with the section cited above in requesting a hospice waiver for R3 and R4, which poses a health and safety risk to persons in care.
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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: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
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