075600075-6-15-2024-15-AS-LHAL-D69RHL-20240615130232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600075
Report Date: 06/15/2024
Date Signed: 06/15/2024 01:02:44 PM

Document Has Been Signed on 06/15/2024 01:02 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 HOME		FACILITY NUMBER:	075600075
ADMINISTRATOR:	BALANCIO, AURORA		FACILITY TYPE:	740
ADDRESS:	23 STEELE COURT		TELEPHONE:	(925) 458-4321
CITY:	BAY POINT	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	06/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Rochelle Balancio, Caregiver		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/15/2024 at 11:25am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Rochelle Balancio, Caregiver, and explained the purpose of the visit. Administrator, Aurora Balancio, arrived at 11:55am. The Administrator certificate #7000305740 3/26/2025. 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 114.6 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 10/23/2023. Emergency Disaster Plan was last posted on 06/22/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/4/2024. Continued on LIC809.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

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: 06/15/2024

NARRATIVE

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Continued from LIC809.

LPA reviewed three (3) staff files. Two (2) of three (3) staff did not have first aid or CPR. All five (5) residents' file were reviewed, current, and complete.

LPA observed the following deficiencies:

At 12:00pm, LPA observed during record review S1 and S3 did not have first aid or CPR certification.

LPA requested the following documents to be submitted to CCLD by 5/24/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan (Last page)
Liability Insurance

Deficiency is 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/15/2024 01:02 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2024

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having all staff with first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have all staff first aid certified and at least one (1) staff per shift CPR certified. Administrator will submit a copy of the certification to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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