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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 04:08:45 PM

Document Has Been Signed on 06/22/2022 04:08 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 6/22/2022 at 3:55PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding care of dementia residents LPA met with Aurora Balancio, Administrator, and explained the purpose of the visit.

While conducting an annual inspection on 6/15/2022, LPA reviewed six (6) of six (6) residents’ files and observed two (2) residents had a diagnosis of dementia. LPA reviewed the facility’s file at Community Care Licensing (CCL) and observed the plan of operation, which has not been updated since 1996, did not include a plan to take care of dementia residents.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency 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: 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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Document Has Been Signed on 06/22/2022 04:08 PM - It Cannot Be Edited


Created By: Laura Hall On 06/22/2022 at 03:58 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2022
Section Cited
CCR
87208(b)

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87208 (b) A licensee who advertises... dementia special care... or environments shall include additional information in the plan of operation as specified in Section 87706(a)(2). This requirement was not met as evidence by:
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Administrator agreed to make an amendment to the facility’s plan of operation to include dementia care and submit it to CCLD by POC date.
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Based on LPAs record review the Licensee did not comply with the section cited above in having a plan for dementia care, which poses a potential 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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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